Prehospital Ethics/Course #: 0103999 – Continuing Education Emergency Medical Responder

First Name *

Last Name *

Organization or Emergency Squad Affiliated with: *

WV Certification # *

Provider Level *

Cellphone Number *

Email Address *

Additional Participants? *

Yes

For each additional participate, please have them register separate to ensure they receive credit.

By clicking "I Agree" below you agree to and understand the following terms: -I understand that this form serves as an electronic signature verifying my participation in session on the date listed above. -I understand that teleECHO sessions may be recorded and I consent to being recorded. - I understand that I must adhere to HIPPA guidelines. I also agree to sign up for text message reminders of the upcoming ECHO and possible surveys or data collection. *

Agree

I do not agree

Signature *

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