*1.First name:(Required.)

*2.Last name:(Required.)

*3.Your agency/organization:(Required.)

*4.Your position:(Required.)

*5.Your cell phone number:(Required.)

*6.Your E-mail address (if possible, please use your official agency or facility email):(Required.)

*7.Confirm your E-mail address (IMPORTANT this is how we will provide all meeting information):(Required.)

*8.Will you attend in-person or virtually?(Required.)

In-person

Virtual

*9.Do you plan to eat at the breakfast for this meeting?(Required.)

Yes

No

N/A - attending virtually

*10.Do you plan to eat at the lunch for this meeting?(Required.)

Yes

No

N/A - attending virtually

*11.Do you have any dietary restrictions?(Required.)

No

Yes (please specify)

*12.Please indicate your discipline(s). Select all that apply.(Required.)

EMS

Fire

Law enforcement

Dispatch

Public Health

Physician

Nurse

Physician Assistant

Coroner

Sanitarian

Emergency Management

Other (please specify)