APPLICATION FORM

Please fill in the form, print, sign and mail to:   

Jimmy Culpepper
9686 GA Hwy 219
Hamilton, GA  31811
Please identify yourself: Emergency Contact Name and Phone Number:
 
Name
Age
Sex Male Female
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Cell Phone
E-mail
Name
   
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Cell Phone
Do you have any allergies to foods, medications, and/or insects? Any disabilities or health concerns of which we should be aware?
If yes please explain:   
 NO    YES  		Explain here:
 
Have you attended any classes before?  NO    YES  
Please select the type instruction you desire
Please select the course you desire
 		Enter the date of the course you would like to attend:
Please select the topics in which you are most interested.  
Note: Use the scroll bar in drop box to view all topics Note: Use the scroll bar in the drop box to view all topics
   
   
What are your goals for this course / class?
How did you hear about us?

WAIVER (all applicants must read and sign this waiver)
In all courses, events and excursions conducted by Georgia Outdoor Skills - it’s assistant instructors, helpers, and Jimmy Culpepper, individually - reasonable care is taken to prevent serious injuries and  minimize accidents. The student states that he or she is in good physical and mental health; and fully aware that survival, primitive technology, eating wild plants, and wilderness travel may be dangerous. The student by signing their name below hereby agrees to accept full responsibility for themselves and assume all risks, including those caused by acts of God, injury, death and/or loss to his or her person and/or property. The student hereby waives all present and future rights to make any claims resulting in any way from attending current or future courses, events or excursions conducted by Jimmy Culpepper, or assistant instructors, and helpers.  
Signature of Student:                Date: 
(DO NOT TYPE - MUST BE WRITTEN SIGNATURE)
OPTIONAL - By initialing below, the student releases Georgia Outdoor Survival Skills to use photographs taken during courses which may contain images of the student, for Georgia Outdoor Survival Skills' advertising purposes.  
 Student's Initials:  (Do Not TYPE- Must be Written Initials)                                                                     

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