Grant Reporting Requirements

When you attend an Oregon EMS Association class that is supported by a grant, the grant funder can require us to request additional information from students. Please complete the following form to allow us to continue providing low-cost, grant supported courses to Oregon EMS providers.

Name *

First

Last

Email *

Registered Course Location & Date *

Race/Ethnicity

EMS/Medical License STATE (select all that apply) *

If EMS/Medical License State is other, please list

EMS/Medical License Type (select all that apply) *

If EMS/Medical License license is other, please list

I attest that I perform EMS/Medical duties that include caring for victims of rural/frontier roadway crashes in OREGON *

Confirm this statement to establish eligibility for the grant-supported course fee. Anyone making a false statement will be expected to reimburse OEMSA the full course cost up to $375 & will not be allowed to attend any future OEMSA courses.

Agency Affiliation

Name of attendee's agency affiliation where rural EMS duties are performed. If not with an agency, type "Unaffiliated." If you are a student, type the school you are attending.

Agency County (not Country)

NAEMT Online Roster: Attendee Agrees to use link to register *

Enroll in NAEMT online course roster prior to class day. This link is provided in your welcome email to fill in the online NAEMT enrollment form. That is how the PHTLS certificate will be generated. The form requires your State EMS license or NREMT certification number so attendees receive CAPCE credit.