EMS-Training-Request-Form - Kern County Public Health

Name*

Date*

Phone Number*

Email*

Organization*

Date of Training*

Start and End Time*

Location of Training*

Estimated Number of Attendees*

Name and Phone Number of Onsite Contact (If Different Than Person Filling Out Form)

Type of Event

Supplies Provided for an Outside Event (Check all that apply)

Supplies Provided for a Classroom Event (Check all that apply)

Other Supplies Provided

Type of Training Requested*