Special Fx Makeup (Moulage) - Beginning to Beyond

The course is funded by the Ga. Trauma Commission and they require that all information be entered

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* 1. First Name

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* 2. We are having to implement a SEAT FEE for GEMSA sponsored Classes due to the 'no shows' we are having the day of class. A $30 Seat Fee will be requested at the end of this application by Credit Card.

After you attend class - within a 30 day period you will receive $25 returned to your credit card. If you cancel prior to the class (for any reason) you will not be reimbursed any funds.

I understand and will comply with this statement

Yes

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* 3. Last Name

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* 4. Email Address

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* 5. Contact Phone Number

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

Home Street Address

Street Address #2 (i.e. apartment number)

City

State

Zip Code

County

Gender

Race/Ethnicity

Age

Place of Employment

Job Title/Role

Years at Current Job

Years Employed in Current Field

Emplyment Location Street Address

Street Address #2 (i.e. Suite Number)

City

State

Zip Code

County

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* 7. Confirm the Location of Course you are attending

May 30, 2025 Bibb County Central Georgia Technical College 3300 Macon Tech Dr, Macon, GA 31206

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* 8. Are you and EMS Provider?

First Responder or EMT - Basic

EMT - I

EMT - A

Paramedic

FF/Medical Responder

N/A

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* 9. If you are a State Certified EMR, EMT or Paramedic - Please list your certification number to include the beginning letter and all 6 digits as in the examples below

for example R045684, I016240, E00001, A00001, P001882

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* 10. I understand that I must complete the 2 day classroom and 'hands on' portion of the class if I am to receive a certificate.

Yes

This Program is made possible by State of Georgia funding provided through the
Georgia Trauma Care Network Commission.

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* 1. First Name

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* 3. Last Name

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* 4. Email Address

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* 5. Contact Phone Number

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

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* 7. Confirm the Location of Course you are attending

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* 8. Are you and EMS Provider?

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* 9. If you are a State Certified EMR, EMT or Paramedic - Please list your certification number to include the beginning letter and all 6 digits as in the examples belowfor example R045684, I016240, E00001, A00001, P001882

Question Title

* 10. I understand that I must complete the 2 day classroom and 'hands on' portion of the class if I am to receive a certificate.

* 9. If you are a State Certified EMR, EMT or Paramedic - Please list your certification number to include the beginning letter and all 6 digits as in the examples below

for example R045684, I016240, E00001, A00001, P001882