Registration Form

                    White Bear Rescue Training Center

                                          P.O. Box 129 Pembine, WI 54156

                                  800-776-7199  Training@atlasoutfitters.com               

Please send (1) Registration Form (2) Insurance Liability Agreement

(3) registration fee

Name:  ____________________________________________________      

Address: _____________________________________________________ 

City____________________________  Zip __________

Department Name:  ______________________________________________

Phone (Preferred)  ________________________    Alt Phone: ________________   

Email:  _________________________________________________________

Course Name: ______________________    Date: ___________________

Camping ($10/night) or Bunking ($15/night) at White Bear:     ___  Yes  ___  No

Signature: _______________________________  PLEASE INITIAL PHOTO RELEASE

qPhotos +/or video taken during class may be used for training, press releases or publicity, including but not limited to catalogs and websites.  Please permit us to use any images of yourself, recognizable or not, by initialing box.

Please note:
This is not a sport or recreational course.  It is a professional training program for rescue and recovery in dangerous environments. 

Your participation must be sponsored through your public safety agency.

The activities encountered during this training can be demanding physically and mentally.  It is important that your respiratory and circulatory systems be in good condition. 

Any person with heart trouble, severe asthma or similar medical problems should not participate.  If you have any medical concerns, consult your doctor and/or the instructor before starting the program.

It is understood that the specific skills and techniques taught in this rescue class do not represent the full scope of possible rescue techniques and skills, and do not cover all rescue scenarios.  Furthermore, it is understood that the effectiveness of these techniques are not guaranteed during actual rescue attempts.

Students in classes held at White Bear Rescue Training Center are not protected for liability under the insurance umbrella of White Bear Rescue Training Center.  You must have a signed liability agreement from your department supervisor to participate.
 

Liability Agreement  PLEASE INITIAL EACH PARAGRAPH AFTER READING

TO: White Bear Rescue Training Center
 P.O. Box 129 l Pembine, WI 54156
 

Student Name:__________________________________________

Department Name: _______________________________________
 

___ This letter confirms that representatives of White Bear Rescue Training Center have been requested to instruct the above named individual in technical rescue skills and techniques.

___  It is understood that these specific skills and techniques do not represent the full scope of possible rescue techniques and skills, and do not cover all rescue scenarios.  Furthermore, it is understood that the effectiveness of these techniques are not guaranteed during actual rescue attempts.

___  The determination that department personnel have the necessary equipment and training; and that conditions are suitable for the safe execution of a rescue attempt, belongs to incident command on scene.  Therefore, the decision to deploy personnel for rescue belongs to incident command on scene; and White Bear Rescue Training Center and their representatives are held blameless from any claim arising from either drills or rescue attempts using techniques demonstrated during this course.

___  We confirm that our department personnel will be covered for injury and liability exposure by our department while participating in this activity.  Each participant will be required to sign a consent and liability release prior to instruction.

___ We understand that it is our responsibility to notify White Bear Rescue Training Center of changes or exceptions in this agreement.
 

________________
Date
 
  ___________________     _____________________   ______________________  

[Supervisor signature]              [Supervisor name]                        [Supervisor position]