April 2018 Rush University Advanced Trauma Training Program Course Registration Form
This information is required to register for the courses. Place "N/A" if an item does not apply to you.
Email address *
Alternate Email Address
Last Name: *
First Name: *
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: *
Required
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 Address *
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. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy