Mile In Our Boots Clinician Academy Registration Mile in Our BootsClinicians Academy Personal InformationName* First Last Email* Cell Phone*Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OrganizationPlease share your counseling specialities.Do you have physical restraints that would keep you from light physical activities Yes No Shirt SizeSmallMediumLargeX-LargeXX-LargeXXX-LargeEmergency ContactPlease provide the name and contact information for your emergency contact.Emergency Contact Name First Last Emergency Contact PhoneConsentsPlease read and check the following consentsBy registering for this course, I here by give the South Carolina First Responder Assistance and Support Team permission to reproduce and publish my name, comments and/or photographic likeness.* Agree Disagree Release*In consideration for participating in South Carolina First Responders Assistance and Support Team's Mile in Our Boots Clinician Academy I hereby release, indemnify, and covenant not to sue the SCFAST or the SC State Firefighters' Association, their officers, agents or employees (Releasees) as well as any other students or instructors from any and all liability, claims, cost and causes of action arising out of or related to any property damage or personal injury, including death, that may be sustained by me, while participating in such activity, or while on the premises owned, leased or used by Releases. I acknowledge the training involves some potentially physically strenuous activities in which I am capable of fully participating. I know of no physical or mental condition that would preclude my full participation in the training. Agree Disagree Refund*To receive a refund for my registration fee, I understand that I must cancel in writing by March 16, 2026 to [email protected] Agree Payment InformationWho Will Pay Registration Fee?* I will be paying online. Please invoice my organization. Conference Registration Fee* Price: Billing Contact First Last Billing Contact Email Enter Email Confirm Email Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name
