EMST Multiple personnel registration form

BUTLER COUNTY EMS TEAM MEMBER REGISTRATION BY OTHER AGENCY STAFF

New Butler County EMS Team members must be fully registered for the EMST to be eligible to participate in EMST emergency responses, training courses, and other EMST activities.

Note: Individual EMST members enrolled on this form will recieve an email requesting additional information to in order to complete their registration with the BCEMST. This form must be completed in order to complete their registration process with the BCEMST.

SPECIAL NOTE: IN ORDER TO ENROLL IN THE EMST YOU MUST HAVE A VALID EMAIL ADDRESS.


BCEMST member agency	*
If "Other" please specify
Today's Date *

Staff Member's First Name	*
Staff Member's Last Name	*
CURRENT certification level? *
Kansas Attendant Certification Number? (found on your certification card/enter "NONE" if non-certified) *
YEAR of expiration? (Enter "NONE" if non-certified) *
Staff Member's frequently checked email address	*

Enter "n/a" in remaining required fields if only registering one person from your department.

Staff Member's First Name	*
Staff Member's Last Name	*
CURRENT certification level? *
Kansas Attendant Certification Number? (found on your certification card/enter "NONE" if non-certified) *
YEAR of expiration? (Enter "NONE" if non-certified) *
Staff Member's frequently checked email address	*

Staff Member's First Name	*
Staff Member's Last Name	*
CURRENT certification level? *
Kansas Attendant Certification Number? (found on your certification card/enter "NONE" if non-certified) *
YEAR of expiration? (Enter "NONE" if non-certified) *
Staff Member's frequently checked email address	*

Staff Member's First Name	*
Staff Member's Last Name	*
CURRENT certification level? *
Kansas Attendant Certification Number? (found on your certification card/enter "NONE" if non-certified) *
YEAR of expiration? (Enter "NONE" if non-certified) *
Staff Member's frequently checked email address	*

Staff Member's First Name	*
Staff Member's Last Name	*
CURRENT certification level? *
Kansas Attendant Certification Number? (found on your certification card/enter "NONE" if non-certified) *
YEAR of expiration? (Enter "NONE" if non-certified) *
Staff Member's frequently checked email address	*

Other Comments

Information entered by:	*
Please provide your email address:	*
Please carefully review all of the information above for accuracy BEFORE pressing the "Submit" button.