P.O.Box 178
Elizabethtown, Kentucky 42702

	Olympics Regional Competition Application

Name			Make check's payable to:
Address			KAEMT EMS Olympics 2006
City			P.O. Box 178
State			Elizabethtown, Kentucky 42702
Zip Code
Employer			Fees mailed in 10 days prior to event $10
Home Phone			Fees mailed in 5 days prior to event $15
Work Phone			Fees paid day of event $20 per event
Cell Phone			KAEMT members save $2.00 per event
Email
Region you live in
Region you work in			Need all information filled out
Region of competition			to process application

Mark one
ALS Individual			Copy of certification must accompany
ALS Team			application or application not accepted
BLS Individual
BLS Team
Rescue Team			Any questions or concerns please contact
			Steve Becraft @ 606-768-3184
			to sbecraft@mrtc.com



Team Members Names
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2
3
4			Thank you for your interest
5			Kentucky Association of EMT's

Team Name