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:

Question Title

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

Question Title

* 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
No file chosen
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

T