1. Print out this application form.
2. Fill out application form.
3. Sign Waiver
4. Mail to:
Full Circle Awareness Center, 4 E. Hazeldell Ave., New Castle, DE 19720
All classes require a $10.00 non-refundable deposit.
In the event you are unable to attend the class if you contact Full Circle Awareness Center
at least 24 hours in advance of the class the deposit can be transferred to another future class.
Full Name : ______________________________________ Gender : Male ____ Female ____
Address : _______________________________________ Date of Birth :_______________
City : ________________________________ State: ___________ Zipcode : __________
Phone : (______)______________ E-Mail : ____________________@______________
Personal Information:
Please list any Medical concerns/conditions/allergies that Full Circle Staff should be
aware of: ______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Emergency Contact Information:
Name: _________________________________________ Relationship:
_______________________
Address:
_______________________________________________________________________________
Phone : (______)______________
Class Information:
Requested Class: __________________________________________ Date : __________________
Waiver
I the undersigned state that I am in good physical health and have informed Full Circle
Awareness Center staff of any medical concerns/conditions/allergies that I currently have.
I understand that there are inherent risks associated with participating in wilderness
classes. I understand that the Full Circle Awareness Center and its staff have taken all
necessary precautions to minimize accidents and injuries when participating in their classes.
In the event of an injury to myself, I absolve Full Circle Awareness Center, its staff and
any visiting guest instructors from any neglect or wrongdoing.
Signature: __________________________________ Date: _____________________