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* 1. First Name

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* 2. Last Name

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* 3. email address

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* 4. Contact phone number

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* 5. Which Class are you interested in attending?

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* 6. 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 assignments prior to initial reporting date of class and I must complete and submit each assignment as directed by the Instructors

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

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* 13. 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.

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

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