Spring 2005 EMS Seminar 
March 5th & 6th, 2005
Degenstein Center
Susquehanna University Campus
Selinsgrove, PA

Online Student Registration Form

By filling out the form below and then submitting it, your form will be processed for the upcoming Spring 2005 EMS Seminar in Selinsgrove being held on March 5th & 6th, 2005. We may contact you by mail, phone or Internet email for further details. In addition, you will be contacted for payment arrangements. Please provide as much information as possible. You can also apply by downloading a brochure or 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):
Certification Level:  
Certification Number:  
   
Conference Participants
 With paid payment by February 16th, 2005
you will receive a FREE conference T-shirt.

T-Shirt Sizes - Please check the appropriate box

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

    

Track I - CISM: Group Crisis Intervention
Saturday, March 5th & Sunday, March 6th
Registration Fee $140.00:
Track II - CISM: Advanced Crisis Intervention
Saturday, March 5th & Sunday, March 6th
Registration Fee $140.00
Track III - Pre-Hospital Trauma Life Support
Saturday, March 5th & Sunday, March 6th
Registration Fee $140.00
Track IV - General EMS Issues (Both Days)
Saturday, March 5th & Sunday, March 6th
Registration Fee $140.00  
Track IV - General EMS Issues (Saturday Only)
Saturday, March 5th 
Registration Fee $85.00
Track IV - General EMS Issues (Saturday Only)
Saturday, March 5th 
Registration Fee $85.00
Track V - Advanced Designated/Infection Control Officer
Saturday, March 5th
Registration Fee $85.00
Track V - Advanced Designated & General EMS Issues
Saturday, March 5th & Sunday, March 6th
Registration Fee $140.00

Terms  

I understand that by submitting this form only temporarily holds me a place in the program I have selected.  I also understand that total payment must be received no later than February 16th, 2005 and only then is my place secure. I further understand that I may cancel prior to the registration deadline of Wednesday, February 16th,2005 and I will receive a total refund.  However, I will not be funded for cancellations after February 16th, 2005.  If I need to cancel, I understand I can substitute another individual.  I understand that "no shows" at the seminar will receive no refunds.


IF YOU AGREE TO THE TERMS, PLEASE TYPE YOUR FULL NAME HERE       


 If needed, please include any additional comments or questions here:

This information collected in this form is for the sole purposes of the above. The information may be shared with subcontractors of the council and/or state. However, no names or other personal information will be disclosed without explicit permission.

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