GEMSA Sponsored - Farm Medic 2025FY Student Application

The course is funded by the Ga. Trauma Commission.

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 $20 returned to your credit card.

If you cancel prior to the class (for any reason) you will not reimbursed any funds.

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Contact Phone Number

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

Home Street Address

Street Address #2 (i.e. apartment number if you do not have a secondary addres you mulst list N/A in this space)

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. apartment number if you do not have a secondary addres you mulst list N/A in this space)

City

State

Zip Code

County

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* 6. Confirm the Location of Course in which you wish to attend:

Jackson County - September 10-11, 2024 1869 County Farm Road, Jefferson, GA 30549

Chatham County, October 26 - 27, 2024 1093 S. Rogers Street (Headquarters) Pooler Ga 31322

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* 7. 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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* 8. Are you and EMS Provider?

First Responder or EMT - Basic

EMT - I

EMT - A

Paramedic

FF/Medical Personnel (EMR, EMT and/or Paramedic)

N/A

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* 9. 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

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* 10. I understand that if I do not pay the Seat Fee requested at the end of this application - my Seat in the class is not secured. I also understand should I cancel for any reason once I register for a class that I will not be refunded any portion of the Seat Fee.

Yes

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

Should you have any questions feel free to reach out to Travis McCoy, Program Coordinator at specialops@georgiaemsassociation.com

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Email Address

Question Title

* 4. Contact Phone Number

Question Title

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

Question Title

* 6. Confirm the Location of Course in which you wish to attend:

Question Title

* 7. 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

* 8. Are you and EMS Provider?

Question Title

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

Question Title

* 10. I understand that if I do not pay the Seat Fee requested at the end of this application - my Seat in the class is not secured. I also understand should I cancel for any reason once I register for a class that I will not be refunded any portion of the Seat Fee.

* 7. 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