TECC - Tactical Emergency Casualty Care Course Application - Georgia EMS Association

All of this information is required

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 be reimbursed any funds.

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* 1. I have reach and fully understand and will comply with the instructions in the above paragraph

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. Contact Information

Home Street Address

Street Address #2 ie Apartment Number If None Please list N/A

City

State

Zp Code

County

Gender

Race/Ethnicity

Age

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* 7. Employment or Sponsoring Agency

Place of Employment

Job Title/Role

Years at Current Job

Years Employed in Current Field

Employment Location Street Address

Street Address #2 (i.e. Suite Number) if none..,,,. please put N/A

City

State

Zip Code

County

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* 8. Please list the ZIP CODE of your PRIMARY Employment Agency

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

November 2 and 3, 2024 - Rabun County

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* 10. Please select your Professional discipline.

FF/Medical Responder (EMR/EMT/Paramedic)

Emergency Medical Services

Law Enforcement

Fire Service

Other (please specify)

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* 11. 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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* 12. 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.

Yes

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

Yes

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* 14. 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

Yes

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* 15.
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 program@georgiaemsassociation.com - 2 weeks prior to class I will receive a $20 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

Yes

Should you have any questions about the registration process please contact Cathy White - GEMSA Operations Chief 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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* 1. I have reach and fully understand and will comply with the instructions in the above paragraph

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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. Contact Information

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* 7. Employment or Sponsoring Agency

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* 8. Please list the ZIP CODE of your PRIMARY Employment Agency

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

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* 10. Please select your Professional discipline.

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* 11. 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

* 12. 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.

Question Title

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

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* 14. 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

Question Title

* 11. 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