Registration Form- Online | Barnes Safety Services Inc.

Registration Form Instructions - Please Read and fill out all required sections.

IMPORTANT- This Form is to be filled out inclass on the first day of the course
Note-For Addresses we require BOTH Street Address and PO Boxes.
Note-A CDN Number is Only required for Transport Canada Marine First Aid Courses
Note- Before Completing the last 4 sections and checking the confirmation boxes, take the time to read the policies on the main webpage under the page "Courses-Safety Info, Liability Waiver, Refund Policy

Name (First and Last) *

Email address *

Telephone Number *

Date of Birth (Day/Month/Year) *

Street Address *

PO Box *

Town/City *

Province/State *

Country *

Postal Code/ZIP Code *

Course Name *

Radio- ROC-MC- 3 day
Radio- ROC-M- 1 Day
First Aid- Basic(Emergency- 1 day)
First Aid- Intermediate(Standard- 2 Day)
First Aid- Marine Basic (2 Day)
First Aid- Marine Advanced (4 Day)

CDN Number(Transport Canada -Marine First Aid Courses *

Course Date you wish to book *

Emergency Contact- Name *

Emergency Contact Phone Number *

Safety Information - Please Read *

I have read and understand the Safety Information Section and agree to its terms

Liability Waiver- Please read and check the box to acknowledge you read and understood the information *

I have read and understand the Liability Waiver and agree to its terms

Medical Conditions/Medications- Please check this box if you have read the information about pre existing medical conditions/ medications that may limit you to complete any courses *

Yes- I have read the information and wish to discuss my situation- Please call or email us
No- I have read the information and have nothing to declare

Fees and Refund Policy- Confirmation *

I confirm I have read the Booking Fees and Refund Policy

Course Payment Options *

Payment Option #1 - EMT /Email Transfer-Check this box and forward EMT Payment to Barnessafetyservicesinc@gmail.com, no password required
Payment Option #2- Credit Card -Check this box and request an Invoice with a secure credit card payment link (Check your email inbox within 1-2 days)