Name*

First Last

Phone*

(###)-###-####

Address*

Street Address City State ZIP Code

Email*

State License Level*

State EMS/Nursing Certification Number*

State EMS Certification Expiration*

Are you a nationally registered provider?*

National Registry Certification Number*

National Registry Expiration Date*

EMS/Fire Department Name*

DAC Course Fee*

Course Date*

Deadline for sign-up is 2 weeks before start date.

Payment Method*

Service Director's Name*

First Last

The person we should send the invoice to.

Service Director's Email*

DAC Signup – Summer

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