GEMSA Sponsored - Farm Medic 2023FY Student Application

The course is funded by the Ga. Trauma Commission.

We are having to implement a SEAT FEE for GEMSA sponsored Classes due to the 'no shows' we are having the day of class. A $30 Seat Fee will be requested at the end of this application by Credit Card.

After you attend class - within a 30 day period you will receive a $20 check mailed to you at the address you listed on your application (or reimbursed to your credit card) along with a small gift. If you cancel prior to 2 weeks of the class you will receive a $20 reimbursement. If you cancel within 2 weeks of the class or do not show up for the class you will not reimbursed any funds.

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

Home Street Address

Street Address #2 (i.e. apartment number)

City

State

Zip Code

County

Gender

Race/Ethnicity

Age

Place of Employment

Job Title/Role

Years at Current Job

Years Employed in Current Field

Emplyment Location Street Address

Street Address #2 (i.e. Suite Number)

City

State

Zip Code

County

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* 6. Confirm the Location of Course in which you wish to attend:

Camden County September 23rd and 24th 2023

Troup County October 27th and 28th 2023

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* 7. Are you and EMS Provider?

First Responder or EMT - Basic

EMT - I

EMT - A

Paramedic

N/A

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* 8. I understand that I must complete the 2 day classroom and 'hands on' portion of the class if I am to receive a certificate.

Yes

This Program is made possible by State of Georgia funding provided through the
Georgia Trauma Care Network Commission.