Kentucky Association of Emergency Medical Technicians

 Mail this form to the address below you will receive an E-MAIL notification that you application has been received and accepted.

Event Date:
-mm/dd/yy    

First Name:

Last Name:

Title:

EMT-B EMT-P EMT-I LPNRNEMT-FREMT-FIREFIGHTER

Street Address:

Town/City:

State/Province:

Zip Code:

Work Telephone:

Home Telephone:

Email address: PLEASE PRINT PLAINLY

All information filled out to process application.

Copy of certification must accompany application or application not accepted

Any questions or concerns please contact Steve Becraft at Phone: 606-768-3184

E-mail: sbecraft@mrtc.com

       ©2000 KAEMT

               Select any of the following EVENTS that you will compete in:
                                             Individual Skill Level

          ALS Individual              

      BLS Individual                   
                 

                Team Skill Level
          ALS Team
      BLS Team
      Team Rescue     

                   Team Members Name

             A 
             B 
             C 
             D 
             E 

                        Team Name
           

   ALL OLYMPIC EVENT SCHEDULING IS 

 SUBJECT TO CHANGE WITHOUT PRIOR NOTICE.
   
        PLEASE PRE- REGISTER 

                         Fees mailed in 10 days prior to event $10
                                 Fees mailed in 5 days prior to event $15
                                 Fees paid day of event $20 per event
           NOTE: Do not mail cash. Cash is accepted at
                                 Olympic locations on the day of the event.

                           Make Checks payable to:

                  Theresa Martin 2007 EMS OLYMPICS

                         Mail to: P.O. Box 178, 

                             Elizabethtown, KY  42702