Infectious Disease Training Course, 16 - 18 July 2019, 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.
Primary Email Address (personal) *
Your answer
Alternate Email Address
Your answer
Last Name: *
Your answer
First Name: *
Your answer
Rank *
Your answer
Home of Record Address (Please include Apt/Unit #) *
Your answer
City/Town: *
Your answer
State/Province *
Your answer
Zip Code *
Your answer
Cell Phone Number *
Your answer
Duty Status *
License Type: *
Required
Emergency Contact Name & Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
Military Unit and State (e.g. 177 MDG, FL ANG) *
Your answer
Training Manager and /or Supervisor Name and Rank/Title: *
Your answer
Training Manager Telephone Number *
Your answer
Training Manager E-mail Address *
Your answer
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 24-72 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
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service