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R1: Crisis at Center Stage Functional Exercise Registration
1.
Name
2.
E-Mail
3.
Phone Number
4.
Organization
5.
What type of role would you like to play? (choose one)
Medical
Non-Medical
6.
If MEDICAL, what are your credentials?
MD/DO
APRN/PA
RN
EMS
Behavioral Health
Pharmacist
Other (please specify)
7.
Is there a specific role you would like to play (medical or non-medical)? If yes, please list here. We will do our best to put you in a preferred role.
8.
Do you have any food allergies or dietary restrictions? (Please list them in the box below. We will make reasonable efforts to accommodate dietary needs.)
By registering for this event, you acknowledge and agree that photographs and/or video recordings may be taken during the event.
You authorize the event organizers to use such materials for promotional, marketing, and educational purposes in print, digital, and social media formats.
