ADLS Registration-May 16 & 17, 2012
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Please complete the following information to register for the Advanced Disaster Life Support (ADLS) training sponsored by the Region 7 Medical Disaster Preparedness Network on May 16 & 17, 2012 at the Grayling Michigan National Guard Base. Please note that you must complete a Basic Disaster Life Support (BDLS) course as a pre-requisite for this more advanced training. Your registration will be confirmed and additional course details provided via email in advance.

1. First Name

First Name

2. Last Name

Last Name

3. Degree/License

Degree/License

4. Organization Name

Organization Name

5. City

City

6. State

State

7. Zip Code

Zip Code

8. Phone Number

Phone Number

9. E-mail Address

E-mail Address

10. Are you enrolled in BDLS training scheduled for May 15 in Grayling?

Are you enrolled in BDLS training scheduled for May 15 in Grayling? Yes (skip to question #12)

No (answer question #11)

11. Date and location of your last BDLS training. (Please bring a copy of your BDLS certificate with you as proof of completion.)

Date and location of your last BDLS training. (Please bring a copy of your BDLS certificate with you as proof of completion.)

12. Please indicate your need for overnight lodging at the Grayling National Guard Base. (Note: ADLS training will run from 9 am to 7 pm on Wednesday, May 16 and continue from 8 am to 4 pm on Thursday, May 17.)

Please indicate your need for overnight lodging at the Grayling National Guard Base. (Note: ADLS training will run from 9 am to 7 pm on Wednesday, May 16 and continue from 8 am to 4 pm on Thursday, May 17.) No lodging needed

Lodging needed for Tuesday night, May 15

Lodging needed for Wednesday night, May 16

ADLS Registration-May 16 & 17, 2012Exit this survey