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* 1. First Name

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* 2. Last Name

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* 3. Employment or Sponsoring Agency

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* 4. Location of Course you are interested in attending:

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

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* 6. Please select your Professional discipline.

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* 7. I understand that by submitting this application I am applying to be accepted to the course.  I will be notified by email as to my 'acceptance' or 'waiting list' status within 2 weeks prior to course.

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* 8. I understand that I must attend and complete all necessary course requirements in order to receive a completion Certificate

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* 9. I understand  **  If I realize that I may not be able to attend this class after registering I will contact Cathy White, GEMSA Program Coordinator at program@georgiaemsassociation.com or 678-283-4542 as soon as possible

Should you have any questions about the registration process please contact Cathy White - GEMSA Program Coordinator at                              program@georgiaemsassociation.com
 
This Program is made possible by State of Georgia funding provided through the
Georgia Trauma Care Network Commission

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