() Basic EMS Medical Director Course

and/or

() Current Trends for EMS Medical Directors

provided in cooperation with the Virginia Department of Health, Office of EMS

• Date and location

Print a copy of this form, complete and fax to 757-258-3042 or register online by clicking here

or call 800-649-4911 for instant registration!

0  I am currently a Virginia EMS Medical Director

0  I am interested in becoming a Virginia EMS Medical Director

0 Virginia EMS Other (i.e. Administrators, etc.)

There is NO FEE for any of the above.

0  All Others………………………………….$139.00 - Basic EMS Medical Director Course

0  All Others............................................... ..$  99.00 - Current Trends for EMS Medical Directors

NAME:_______________________________________________________________________________

POSITION:___________________________________________________________________________

AGENCY:____________________________________________________________________________

ADDRESS:__________________________________________________________________________

 _________________________________________________________________________________________________

PHONE:__________________________________

EMAIL:_____________________________________________________________

Method of Payment (if required)

0  Check *                        0  MasterCard            0  VISA                            

CREDIT CARD NO.:________________________________________ EXPIRE DATE:____________

SIGNATURE:________________________________________________________________________

*MAKE CHECKS PAYABLE TO VaCEP AND MAIL TO P. O. BOX 911, NORGE, VIRGINIA 23127-0911

FOR INSTANT REGISTRATION CALL

800-649-4911 or 757-220-4911

or FAX to:  757-258-3042

CONFIRMATIONS WILL ONLY BE SENT VIA EMAIL

CANCELLATION POLICY

Cancellations & requests for refunds must be submitted in writing and received 10 days prior to scheduled Course date. 

Substitutions are acceptable.