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SEMINAR REGISTRATION

Name___________________________

Address_________________________

City:_____________St/Zip__________

Phone____________EMS Reg______

Email___________________________

EMS Region_____________________

Please indicate your registration selection:

_____Active Shooter $50 Thursday

_____PALS$125 Thursday

_____EMS Billing Forum $50 Thursday

_____Full Conference

$185 (KEMTA Member ( If membership is renewed effective 1-1-12)

$210 Non-Member (Conference &

KEMTA Membership of $25.00)

_____Friday Only $95 (lunch included)

_____Extra Lunch Tickets $15 (#______)

_____Extra Banquet Tickets $25 (#______)

_____Sunday Only $40

_____Nursing Hours $35

_____TOTAL AMOUNT ENCLOSED