AEMTA EMS Conference 2009
Online Registration Form

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Please complete and submit form below.  After submission, you will be directed to pay for your membership with PayPal.  Your registration will not be complete without payment. You do not need to be a member of PayPal to pay using this method.

STOP! If you do not intend on paying for this conference using PayPal, please do not use this online registration form.  Please click here to download a printable, mail-in conference registration form. 

Full Name:    Arkansas EMT #: 
Employer/Representing:
Date of Birth
(for membership only)		 (mm/dd/yyyy)
Home Address:
City:  State:   Zip:
County:  
Home Phone: (xxx-xxx-xxxx)   Cell Phone: (xxx-xxx-xxxx)
Work Phone: (xxx-xxx-xxxx) 
Email Address:
T-Shirt Size: For registrations after 7/19, T-shirt sizes cannot be guaranteed and will be subject to availability.
Affiliation(s): (hold Ctrl for multiple selections)

Do you plan to attend the awards banquet on Saturday, Aug. 1, 2009?

CONFERENCE REGISTRATION
(click appropriate boxes)

    Before 7/15/09 After 7/15/09
Full Conference Registration

AEMTA Member

 $125 $150
  Non- AEMTA Non-Member** $150 $175
Extra Banquet Ticket $40 $40
Classes S.T.A.B.L.E. Class -- Class is Free; Book is $40 $40 $40
Trauma for First Responders by PHTLS $80 $80


Both classes are on Thursday from 10 a.m. to 5 p.m. The Trauma for First Responders class is limited to 20 students.
One Day Registration Receives conference bag only $50 $50
  Select Day Attending:
    
Two-Day Registration Receives conference bag & T-shirt only $85 $85
  Select Days Attending (control + click):
    
       
** - You may join the AEMTA on this registration form and receive the member price

2010 AEMTA MEMBERSHIP DUES
(click appropriate boxes)

AEMTA
 AEMTA Membership

$20

  
  AEMTA Associate Membership
 (Out of State EMS, RNs, LPNs, Physicians, etc.)		 $15  

Societies

 Industrial Society $10  
  Fire/EMS Society $10  
  First Responder Society $10  
  Instructor/Coordinator Society $10  
  Paramedic Society $10  

DONATIONS

  I would liketo donate to the Arkansas Ambulance Association Scholarship Fund  
  I would like to donate to the Arkansas EMS Foundation Scholarship Fund.  
  I would like to donate to the Wannell Bradshaw Benevolence Fund  
 

SPECIAL NEEDS

Please tell us if you have any special needs:

After Submission, you will be taken to registration payment page


(submit only once)

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