17-21 April 2023 TCCC-CLS Course Rush University Advanced Trauma Training Registration Form
This information is required to register for the courses. Place "N/A" if an item does not apply to 
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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 *
Duty Status
License Type: (click N/A) *
Required
License Number (answer N/A) *
License State of Issuance (answer N/A) *
License Expiration (answer 01/01/2025) *
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National Registry EMT Number (answer N/A)
National Registry EMT Expiration Date (answer 01/01/2025)
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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 Address *
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 21 days prior to the first day of my course will be subject to a 40% penalty fee of the published rate.   *
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