September 2019 Rush University Advanced Trauma Training Program Course Registration Form with optional AHLS (12,13 September)
This information is required to register for the courses. Place "N/A" if an item does not apply to you.
Primary Email Address (personal) *
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Alternate Email Address
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Last Name: *
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First Name: *
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Rank *
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Course you are registering for: *
Home of Record Address (Please include Apt/Unit #) *
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City/Town: *
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State/Province *
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Zip Code *
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Cell Phone Number *
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Duty Status *
License Type: *
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License Number *
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License State of Issuance *
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License Expiration *
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National Registry EMT Number
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National Registry EMT Expiration Date
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T-Shirt Size *
Emergency Contact Name & Relationship *
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Emergency Contact Phone Number *
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Military Unit and State (e.g. 177 MDG, FL ANG) *
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Training Manager and /or Supervisor Name and Rank/Title: *
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Training Manager Telephone Number *
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Training Manager E-mail Address *
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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. *
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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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