Education Center Application

Base Medical Certified Education Center Application

Organization Information

* Indicates required field

Organization Name *

Location of Organization *

Website Address *

Organization Member Size *

Description of Organization *

Type *

Please list your current wilderness medicine education provider if you have one. *

Contact Information

Point of Contact Name *

First

Last

Position *

Email *

Phone *

Instructor Candidates

One of the requirements to become a Base Medical Certified Organization is to certify a member or several members from your organization as an instructor.

Do you have individuals selected as potential instructor candidates? *

How many potential instructor candidates? *

What is the general experience of the instructor candidates? *

When do you hope to offer your first wilderness medicine course? *

How do you plan to use our program? *

How did you hear about Base Medical? *

Submit