GEMSA sponsored - Auto Extrication with Focus on Patient Care/Handling Operation Level

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 $25 reimbursement to your credit card to the email address you listed on your application If you cancel prior to 4 weeks of the class you will receive a $20 reimbursement. If you cancel within 4 weeks of the class or do not show up for the class 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

Secondard Address line..... if not needed please list N/A

City

State

Zip Code

County - like Dekab, Tift, Lowndes (NOT Country)

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 none please list N/A

City

State

Zip Code

County - like Dekab, Tift, Lowndes (NOT Country)

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* 6. Confirm the Location of Course in which you wish to attend: the Lowndes Co. May 28-30 is full. If you would like to be put on the waiting list. Please contact Cathy. Program@georgiaemsassociation.com.

Gordon County - June 25 - 26 - 26, 2025
Gordon County Fire Rescue Station 1. 218 Public Safety Drive Calhoun Ga 30701
,Parrish Towing Lot: 315 ,Crossplains Blvd SE, Dalton, GA 30721

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* 7. Would you like to add a seondary email address - for contact .... if not please write N/A

Secondary email address

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* 8. Are you and EMS Provider?

FF/First Responder or EMT - Basic

FF/EMT - I

FF/EMT - A

EMR - EMT or Paramedic

Other

If you have an State EMS Certification Number Please list it here

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* 9. Why do you want to take this class

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* 10. I understand that the Grant covers my attendance to the class and lunch. Lodging is NOT included

Yes

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* 11. I understand that I must attend the full course in order to receive a completion Certificate

Yes

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* 12. I understand that when I submit my application - I will be directed to a page to pay a $30 seat fee by credit card. This will secure my seat in the class. After I attend the class or if I cancel by email to klwhitercfd@gmail.com - 4 weeks prior to class I will receive a $25 refund on my credit card.

If I do not pay my seat fee at the end of this registration I understand that my application will be rejected and I am NOT registered for the class

ALSO Once you register for class - you have secured your spot for this particular class - you are not allowed to request to change class locations. You have secured a spot in the class you have registered for and eliminated the possibility of someone else signing up for this class.

Yes

You will be contacted at least 2 weeks prior to the class concerning class details. If you have questions please contact Keith White at klwhitercfd@gmail.com or 678-283-0074

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