AUXCOM Class - Delco

1. Registration Form

Thank you for taking the time to register for the AUXCOM course being held on November 17, 2012 & November 18, 2012 at the Delaware County Emergency Services Center, 360 N. Middletown Road, Media, PA 19063. The course will begin daily at 8:00am and conclude at 4:30pm. If you have any questions or need additional information, please contact Christine Leonardo at cleonardo@separtf.org.

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1. Please complete the following:

Name: *

Agency: *

Address: *

Address 2:

City/Town:

State:

ZIP:

Email Address: *

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2. Please indicate the Regional Task Force Work Group which you belong:

Critical Infrastructure

Fire Fighting, US&R, Hazardous Materials

Human Services

Interoperable Communications

Private Sector Outreach & Coordination

Public Health, Hospitals, and EMS

Public Information

Public Safety & Security

Public Works, Engineering, & Transportation

Schools

Regional Task Force Executive Board

Regional Task Force Staff

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3. Please indicate any accommodations that would allow us to best assist you while attending the course:

Language Interpretation

ASL Interpreter

Diet Restrictions (Please describe below)

Other (Please describe below)

Additional details/Other:

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4. Please list any suggestions you may have for this or future programs:

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5. Agreement to Terms:

I acknowledge it is the policy of the Southeastern Pennsylvania Regional Task Force to provide availability for attendance in courses based on minimum and maximum enrollment requirements and that I must attend a course that I have registered, unless I provide notification 72 hours prior to the start of the course. I understand if I or my authorizing supervisor does not cancel participation in the course 72 hours prior to the start of the course then administrative sanctions may be levied up to and including prohibition from registering from courses for one year.

Yes, I agree with the terms.

No, I do not agree to the terms.