Emergency Pediatric Care
Sponsored by GEMSA and Ga. Trauma Commission

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* 1. First Name

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* 2. Last Name

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* 3. Employment or Sponsoring Agency

Agency

Full Address

Work Phone Number

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* 4. Location of Course in which you wish to attend:

Coweta County, Bremen August 12-13, 2020
Fairgrounds 275 Pine Road Newnan, Ga 30263

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

Cell Phone Number

Home Phone Number

Mailing Address (include Street, City, State and Zip Code)

EMAIL address

secondary EMAIL address (if none list n/a)

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* 6. Please select your Professional discipline.

Fire Service

Emergency Medical Services

Law Enforcement

Other (please specify)

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* 7. I understand that I must attend both days and complete all necessary course requirements in order to receive a completion Certificate

Yes

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* 8. I confirm that I am 18 years of age or older.

Yes

You will be notified by email for further instructions on the class

Should you have questions - Contact Jenny Weatherby at jweatherby@coweta.ga.us

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