Introduction to EMS Leadership Program Application - 2025 Offering
All applications must be completed and submitted by 5pm on April 15, 2025.
This class covers your Room, Meals and Class.

The course is funded by the Ga. Trauma Commission and they require that all information be entered

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* 1. First Name

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* 2. 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 $20 returned to your credit card. If you cancel prior to the class (for any reason) you will not be reimbursed any funds.

I understand and will comply with this statement

Yes

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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. Select Location you wish to Attend

Morgan County - Hard Labor Creek State Park June 1 - 3 2025

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* 7. 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 (ie Tift, Ware, Habersham - NOT United States)

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 (ie Tift, Ware, Habersham - NOT United States)

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* 8. Are you and EMS Provider?

First Responder or EMT - Basic

EMT

Paramedic

Fire Fighter and Medical Responder

N/A

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* 9. If you are a State Certified EMR, EMT or Paramedic - Please list your certification number to include the beginning letter and all 6 digits as in the examples below If we have these credentials then we can enter your CEUs into the State Office of EMS Learning Management System for you.

for example R045684, I016240, E00001, A00001, P001882

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* 10. 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.