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Virginia LEAP: PCIS Registration
Please fill out all of the questions.  When you have completed filling them out, submit them.  
If you have any questions, please contact us at adamblevins.valeap@gmail.com or kitcummings.valeap@gmail.com.
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Name *
Enter your full name here.
Name Tag *
How should your name appear on your nametag?
Address (Street, City, State, Zip) *
Personal Phone Number, not agency number* *
Personal or most monitored Email* *
Select which PCIS you would like to attend. *
Required
Are you registering as yourself or on behalf of another?
Clear selection
Gender (for room assignments) *
Are you a sworn officer? *
T-shirt Size *
Emergency Contact (Email address, address, phone number) *
Agency (Name, address, phone number) *
Please let us know what type of critical incident you have experienced. Provide non-specific details, leaving out dates, names, and locations. *
Submit
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