TRAUMA SKILLS PROCEDURE LAB

New TRAUMA SKILLS PROCEDURE LAB LIMITED SPACE LIMITED SPACE- Serious Inquiries Only*** Ple

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 a $20 check mailed to you at the address you listed on your application (or reimbursed to your credit card) along with a small gift. If you cancel prior to 2 weeks of the class you will receive a $20 reimbursement. If you cancel within 2 weeks of the class or do not show up for the class you will not reimbursed any funds.

(Understand... once you sign up for a Lab - Please do not email me asking to swap to another Lab - We will not swap you over to another Lab)

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* 1. I fully understand and will comply with the statement above

Yes

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* 2. 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)

Home Street Address

Street Address #2 (i.e. apartment number) if no secondary enter N/A

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) if no secondary enter N/A

City

State

Zip Code

County

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* 7. Select the Course Location and Time Slot you Wish to Attend

Laurens County November 17, 2023 Morning Session 0730-1130

Laurens County November 17. 2023 Afternoon Session 1200-1600

Emanuel County December 15 2023 Morning Session 0730 - 1130

Emanuel County December 15 2023 Afternoon Session 1200-1600

Muscogee County January 26, 2024 Morning Session 0730-1130

Muscogee County January 26, 2024 Afternoon Session 1200-1600

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* 8. You understand that if you do not pay the seat fee your application may be rejected

Yes

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* 9. Are you and EMS Provider?

First Responder or EMT - Basic

EMT - I

EMT - A

Paramedic

Firefighter

Firefighter/EMT

Nurse

Respiratory Therapist

other

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