* 1. Todays Date

Date / Time
/
/
:

* 2. What is your first name?

* 3. What is your last name?

* 4. What Department / Organization do you represent?

* 5. What is your current job assignment?

* 6. Number of years in Public Safety

* 7. Hotel Accommodations. (If your commuting more than 50 miles, rooms will be provided., select the appropriate answer below. Rooms will be provided the nights of the 14th and 15th only. Rooms will be provided double occupancy, unless you request a single room, you will be responsible for half of the room cost if you select a single room.

* 8. Telephone number

* 9. Mailing Address

* 10. Primary email address

* 11. Confirm primary email address

* 12. Secondary email address

* 13. Are you an EMS Provider?

* 14. Previous extrication training.

* 15. Select any current instructor credentials you hold.

* 16. I understand I must attend the course in its entirety to receive credit.

* 17. An Authorization to Participate will be required to attend this course, Please provide below your supervisor's name, primary phone number, and primary email address that will be authorizing you to participate in this course.

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