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 reimbursement to your credit card to the email address you listed on your application 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. Employment Information

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* 4. Please list the ZIP CODE of your PRIMARY Employment Agency

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* 5. Current Assignment Information

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

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

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* 8. Are you and EMS Provider?

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* 9. What vehicle extrication experience do you have?   Please be descriptive to include any certification you hold

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* 10. Why do you want to take this class

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* 11. I understand that the Grant covers my attendance to the class and lunch.  Lodging is NOT included

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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 when I submit my application - I will be directed to a page to pay a $30 seat fee by credit card. This will secure my seat in the class. After I attend the class or if I cancel by email to klwhitercfd@gmail.com   -  2 weeks prior to class I will receive a $20 refund on my credit card.

If I do not pay my seat fee at the end of this registration I understand that my application will be rejected and I am NOT registered for the class

ALSO   Once you register for class - you have secured your spot for this particular class - you are not allowed to request to change class locations.  You have secured a spot in the class you have registered for and eliminated the possibility of someone else signing up for this class. 

You will be contacted at least 2 weeks prior to the class concerning class details.  If you have questions please contact Keith White at klwhitercfd@gmail.com      or    678-283-0074
This Program is made possible by State of Georgia funding provided through the
Georgia Trauma Care Network Commission.

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