SEHSC - Spring Seminar 2008
Online Student Registration Form

Complete the form below, Print it and mail it and payment to 249 Market St., Sunbury PA 17801. Your form will be processed for the 2008 Spring Seminar sponsored by the Susquehanna EHS Council. We may contact you by mail, phone or Internet email for further details. To secure your seat you must send your payment immediately.  Please provide as much information as possible. You can also apply by calling Laura Rompolski at the SEHSC council office at 570-988-3443 or sending an e-mail to secretary@sehsc.org

When filling out the form, use the TAB key or your mouse to go to the next data area. Use the scroll bar to scroll down the form.

Your First Name:
Your Middle Initial:
Your Last Name:
Your Email Address:
Your Date of Birth:   ( mm / dd / yyyy )
Social Security No:   ( 123-45-6789 )
Street Address 1:
Street Address 2:
City:
State:
Zip code:
Telephone:
County of residence:
Regional EMS Council:
EMS Primary Affiliation (ambulance/QRS/fire company):

To Register For a Program, Choose The Drop-Down Menu Next To The Items You Want  

    

   

 

Conference Participants

With paid payment by February 1st,

you will receive a FREE

Conference T-Shirt.

Please check the appropriate size.

 

T-Shirt Sizes - Please check the appropriate box.

 

Small

 

Med

 

Large

 

XL

 

2XL

 

3XL

 

4XL

 

 

 

 

 

 

 

 

 

 

 

 

 

 
   

 Track I - CISM: Group Crisis Intervention

     Saturday, March 1 and Sunday, March 2

      Registration Fee $140.00
   

  Track II - PHTLS

       Saturday, March 1 and Sunday, March 2

        Registration Fee $140.00
   

  Track III - General EMS Issues (Both Days)
        
        Saturday, March 1 and Sunday, March 2

         Registration Fee $140.00
   
   

 Track III - General EMS Issues (Saturday Only)

         Saturday, March 3rd

         Registration Fee $85.00
   

Track III - General EMS Issues (Sunday Only)

         Sunday, March 4th

         Registration Fee $85.00