GEMSA - North American Heavy Rescue Extrication Symposium - Application

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* 1. First Name

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* 2. Last Name

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* 3. What Georgia County do you work in?

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* 4. What Georgia EMS Region do you live or work in?

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

Region 8

Region 9

Region 10

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* 5. Name of Employment Organization or Sponsoring Agency

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* 6. Current Assignment Information

Describe your current job assignment (ie ambulance, squad, engine)

Number of year in Public Safety

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

Covington, Georgia North American Heavy Rescue Symposium June 4-7, 2019

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

Telephone Number

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

email address

Re-enter your email address for confirmation

secondary email address

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* 9. Are you an EMS Provider?

First Responder or EMT - Basic

EMT - I

EMT - A

Paramedic

N/A

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

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* 11. Please advise if you need a hotel room and what option you prefer:

I need a hotel room - double occupancy with another participant at GEMSA covering 100% of the cost.

(Single Occupancy with GEMSA covering any portion of cost is NOT available for this course)

I don't need a hotel room.

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* 12. If you need a hotel room, please select the dates you need a hotel room:

Night of June 3

Night of June 4

Night of June 5

Night of June 6

Night of June 7

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* 13. It is a requirement that you upload your 400-500 word essay below with this application to be considered for sponsorship. Topic: "Why my attendance to the course will help my community."
(If you do not upload your essay your application will not be considered)

PDF, DOCX, JPEG, JPG, DOC file types only.

Choose File

Information will be emailed to you soon to notify you of acceptance or waiting list status.
Should you have questions - Contact Keith White at klwhitercfd@gmail.com or Cathy White at program@georgiaemsassociation.com

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. What Georgia County do you work in?

Question Title

* 4. What Georgia EMS Region do you live or work in?

Question Title

* 5. Name of Employment Organization or Sponsoring Agency

Question Title

* 6. Current Assignment Information

Question Title

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

Question Title

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

Question Title

* 9. Are you an EMS Provider?

Question Title

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

Question Title

* 11. Please advise if you need a hotel room and what option you prefer:

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* 12. If you need a hotel room, please select the dates you need a hotel room:

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* 13. It is a requirement that you upload your 400-500 word essay below with this application to be considered for sponsorship. Topic: "Why my attendance to the course will help my community."(If you do not upload your essay your application will not be considered)

* 13. It is a requirement that you upload your 400-500 word essay below with this application to be considered for sponsorship. Topic: "Why my attendance to the course will help my community."
(If you do not upload your essay your application will not be considered)