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* 1. First Name

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* 2. Last Name

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* 3. Employment or Sponsoring Agency

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

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

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* 6. Please select your Professional discipline.

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* 7. List All Instructor Certifications or Instructor Qualifications you may have

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

Information will be emailed to you soon after the 'deadline' of the class to notify you of acceptance or waiting list status.    
Should you have questions - Contact  Cathy White, GEMSA Program Coordinator at program@georgiaemsassociation.com
This Program is made possible by State of Georgia funding provided through the Georgia Trauma Care Network Commission.

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