Kent Mountain Adventure Center

ELC Enrollment Application

                                             P.O. Box 835  •  Estes Park, CO  80517  •  (970) 586-5990 • kmac@frii.com

                                                                                           To be filled out by Participant

COMPLETED  FORM  IS  REQUIRED

Participant Name ____________________________________________D.O.B.______/______/______   Age: 

Gender: 

                                   

Address/P.O. Box  ____________________________________________________________________________________

City ________________________________________________  State __________  Zip_____________

Course Applying For:  _________________________

 

Physical Condition (circle one)     Excellent      Good      Fair     Poor                        

Participant Email_____________________________________ 

Participant Phone:____________________________________

 

 

Name of Participant's Physician __________________________________________________________________

Name of Office or Clinic: _______________________________________________________________________

Address:____________________________________________________________________________________

Phone (_________)______________________________________________________________________

City________________________________________  State ________________  Zip _________________

 

Please include a copy of participant's latest medical physical.

A non refundable $200 deposit must be included with this application. The deposit will be applied to the full course tuition. Reservations cannot be accepted without full payment of this deposit. Deposits will be refunded only if placement is not possible. The remaining balance of the course tuition must be paid in full two weeks before course start date. Tuition (minus deposit) will be refunded only if KMAC is notified of cancellation two weeks before course start date. Course cancellation insurance is available from your local insurance professional.

Acceptance of Terms
The undersigned certifies that all information submitted on this form is true and correct, and understands and accepts the payment and refund provisions.

Signed: _______________________________________________ Date: ___________

Enrollment Application Instructions:
Email or mail completed application form to Kent Mountain Adventure Center.  Send via US post mail a check or money order  of $200 deposit. Upon receipt of enrollment application and deposit, the following forms will be emailed:

-  confirmation letter

- consent

-  medical

-  equipment list

-  course overview and itinerary