SD EMSA District 4’s 20-Hour Spring Conference

First Name *

Last Name *

Street Address *

City *

ZIP / Postal Code *

Phone *0 / 10

State EMS # *

Email Address *

Service Associated with *

I would prefer *in-personvia internetno preference

Registration Fee *$55-SD EMSA member ($56.25 for credit card)$105-Non-SD EMSA member ($106.25 for credit card)Optional: $30-SDEMSA membership (Save on the refresher by joining the state association. Total of $85 ($86.25 for credit card) to join SDEMSA and attend the refresher.)

Registration Payment *Check: Please include check payable to: District IV (Mail to: Jackie Rau Box 120 Leola, SD 57456)Credit Card: Jackie Rau will follow up with you for this payment form.

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