Team Name*:
Team Affiliation: (School/Hospital/Organization/etc.)
Hometown: (City, State/Providence)

Race Course
3 Loop Regular Course
4 Loop Advanced/Expert Course

Team Captain

First Name*: Last Name*:
Occupation: (MD/DO/RN/EMT/WFR/Student/etc.)
Email*:
Street Address*:
City*: State/Province*: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Not Applicable
Country*: U.S.A. Canada Other (enter below) If other, Country:
Zipcode*:
Phone Number:
T-Shirt Size* S M L XL
CME/CUE credit: Yes No

Team Member 2

First Name*: Last Name*:
Occupation: (MD/DO/RN/EMT/WFR/Student/etc.)
Email*:
T-Shirt Size* S M L XL
CME/CUE credit: Yes No

Team Member 3

First Name*: Last Name*:
Occupation: (MD/DO/RN/EMT/WFR/Student/etc.)
Email*:
T-Shirt Size* S M L XL
CME/CUE credit: Yes No

Canoe Rental* ($20/team, includes boat, paddles, pfds, and transport of canoe)
Yes, please reserve a canoe for us.
No, we will bring our own.

Questions/Comments