Wilderness Medical Society - SIG Registration Forms (Page 3)

Wilderness Medical Society SIG Registration Forms Page 3

Institution: University of

Academic Year: 2004

College of Medicine

SIG Membership Form

Student Information:

Name:

Address:

Country:

Telephone:

E-mail:

In addition to the above contact information, please provide the following:

· Dues payment of

$20.00

(Checks payable to the Wilderness Medical Society)

Please send this form and dues payment to the following address:

Wilderness Medical Society
Student Membership
3595 E. Fountain Blvd., Suite, A1
Colorado Springs, CO 80910

v. 6-Apr-04

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