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* 1. I understand that if accepted to the class and my schedule changes - I will notify GEMSA so that any applicants on a 'waiting list' will be given the opportunity to attend. Also due to the popularity of this course - a $30 non-refundable Seat Fee will be required. This is required from past experience of applicant signing up and then withdrawing from the class 2 weeks prior of class.

I also understand that once I sign up for a class.... I will not be allowed to 'switch' to one of the other EMS Instructor Preparedeness classes that is posted on the GEMSA webiste.

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* 2. First Name

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* 3. Last Name

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* 4. email address

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* 5. Contact phone number

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* 6. Which Class are you interested in attending? (This is the first of 4 classes we will conduct within the next few months)

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* 7. Your contact information (if no secondary email address available please list N/A)

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* 8. Employment Information

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* 9. Please list any and all current teaching credentials or experience

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* 10. Please list your EMS experience

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* 11. I understand (if accepted to course) that I will receive course contract (That you must read/initial/sign and return within 5 business days of receipt) and the 4 assignments will be sent by email and expected to be completed and return 1 month prior to initial reporting date of class

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* 12. I understand that I must attend the full course in order to receive a completion Certificate

Accomodations and Reimbursements:
1. If you live within 50 miles or commute daily to the class location - the funding will cover your attendance to the class only

2. If you live further than 50 miles from location -
Hotel Accomodations will be made for you at DOUBLE OCCUPANCY -

If you desire SINGLE occupancy - you will be expected to cover 1/2 of the hotel cost (GEMSA will only cover 50% at the hotel that GEMSA Books for you)

You must provide a completed and signed W9 - for GEMSA to send you a per diem check for dinner for 3 days at the Georgia State per diem rate

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* 13. You have read and acknowledge the Accomodation and Reimbursment policy above

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* 14. Do you need Hotel Accomodations

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* 15. If you answered YES to the above question - Please select your Accomodations

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* 16. For Hotel Accomodations Please select Gender

Should you have any questions please contact Daniel Warren or Cathy White.

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