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

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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: (The Rabun Co Course is full)

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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 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.

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* 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

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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

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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