August 2025 Rush University International Surgical Advanced Trauma Training Program Course Registration Form.  IATTC: 25-29 August.  (IATTC Travel days are 24 and 30 August).  
This information is required to register for the courses. Place "N/A" if an item does not apply to you.
Sign in to Google to save your progress. Learn more
Last Name: *
First Name: *
Primary Email Address (personal) *
Alternate Email Address
Rank *
Course you are registering for: *
Home of Record Address (Please include Apt/Unit #) *
City/Town: *
State/Province *
Zip Code *
Cell Phone Number *
License Type: *
License Number *
License State of Issuance *
License Expiration *
MM
/
DD
/
YYYY
National Registry EMT Number
National Registry EMT Expiration Date
MM
/
DD
/
YYYY
T-Shirt Size *
Emergency Contact Name & Relationship *
Emergency Contact Phone Number *
Military Unit and State (e.g. 177 MDG, FL ANG) *
Training Manager and /or Supervisor Name and Rank/Title: *
Training Manager Telephone Number *
Training Manager E-mail  *
Email Government Purchase Card (GPC) Holder who will make the payment.  (must be the GPC holder; invoice required to be billed to them). *
By sending this registration, I agree to hold Rush and its contractors/affiliates harmless of any illness or injury that may occur during my training event. *
Required
You will receive an email within 48-72 hours confirming your acceptance.  If I am accepted into the course, I acknowledge I am reserving a training seat for the course I selected above. I further understand that I am required to have a payment document furnished to Rush NLT 30 days prior to the beginning of my training segment and any cancellations 14 days prior to the first day of my course will be subject to a 40% penalty fee of the published rate.   *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms