EMS on the Hill Registration

REGISTRATION FORM

Please complete and submit this form to confirm your participation in EMS on the Hill Day 2012, March 20-21, 2012, in Washington, D.C. In order for us to schedule appointments with your congressional representatives, you must register by February 15, 2012.

Please note: When completing the registration, you must use your HOME ADDRESS, as this is the address we must use to identify your Members of Congress with whom we will schedule your meetings. Your phone number should be the cell number at which you can be reached while in Washington, D.C. for EMS on the Hill Day.


PERSONAL INFORMATION

First Name *
Last Name *
Middle Initial

	Home Address
Street *
City *
State*
Zip*

Cell Number*
E-mail Address*

PROFESSIONAL INFORMATION

EMS Agency or Organization*	If not applicable, enter N/A
Title
Medical Position*

The Washington Plaza Hotel has been selected as the host hotel for this event. The room rate is $249 single or double, and rooms are limited. To make your reservations, call 1-800-424-1140.

A nominal registration fee of $20 is being charged to help offset the cost of scheduling. This registration fee is non-refundable after February 15, 2012. Please check the box below to confirm your participation in EMS on the Hill Day and complete the registration process.

Please check here to confirm your participation in EMS on the Hill Day *

Yes - I plan to participate.