All Hazards Medical Response

395 Griffin Road, Bangor, Maine

This is a free training. Funding and guidance provided by the Maine CDC.

Registration Form

Please fill out the Registration form below completely. Fields marked with an * are required.

Please Do Not Use Acronyms.

Deadline to register is March 3, 2008.

First Name:*   Last Name:*   

(as you wish it to appear on name badge)

Job Title:* 

Organization/Agency:  

Mailing Address:*  

Address 2:  

City:*   State:*   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nevada New Hampshire New Jersey New Mexico Nebraska North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip:*  

Phone:*   (000-000-0000)

Fax:   (000-000-0000)

E-mail:*   

Please check the job description that best matches your PRIMARY position. Check only one box.

Breakfast and Lunch will be provided.

For more information please contact: Jill Lathan (jlathan@emh.org), 207-973-9548

There are services available for the disabled.  If special arrangements are required for an individual with a disability to attend this program please contact Jill Lathan (jlathan@emh.org), 207- 973-9548 prior to the March 3^rd registration deadline.

Eastern Maine Medical Center, Education and Training Center, is an approved provider of continuing nursing education by ANA-Maine, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

6 Contact Hours provided, based on a 60 minute contact hour as of January, 2008.

Eastern Maine Medical Center is accredited by the Maine Medical Association and the AMA Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Eastern Maine Medical Center designates this educational activity for a maximum of 6 AMA PRA Category 1 Credits ^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.