MedSpec Registration Form

Urban Search & Rescue

Medical Team Specialist Course
Jan 31 – Feb 3, 2023

On-site housing and meal plan are additional and available at discounted rates through the FSFC. (352) 369-2818

Participant Registration

Task Force Information

Requestor Individual AgencyFirst Name Last Name Task Force: AddressAddress Line 1 City State Zip Code Country Agency: Rank/Position Phone/Mobile Email

Participant Information

Note to Agencies: Please provide student’s address information for mailing of pre-course and/or enrollment confirmation.

Number of Participants Level of Training: First Name Last Name AddressAddress Line 1 City State Zip Code Country Task Force: Rank / Position Email Phone/Mobile D.O.B. Name as Appears on Badge:

Participant #2

First Name Last Name Level of Training: AddressAddress Line 1 City State Zip Code Country Task Force: Rank / Position Email Phone/Mobile D.O.B. Name as Appears on Badge:

Participant #3

First Name Last Name Level of Training: AddressAddress Line 1 City State Zip Code Country Task Force: Rank / Position Email Phone/Mobile D.O.B. Name as Appears on Badge:

Participant #4

First Name Last Name Level of Training: AddressAddress Line 1 City State Zip Code Country Task Force: Rank / Position Email Phone/Mobile D.O.B. Name as Appears on Badge:

Participant #5

First Name Last Name Level of Training: AddressAddress Line 1 City State Zip Code Country Task Force: Rank / Position Email Phone/Mobile D.O.B. Name as Appears on Badge: Payment Amount $ USD Payment Method Credit Card Purchase OrderPay with Card (Stripe)

MedSpec Registration Form

Urban Search & Rescue

Medical Team Specialist Course Jan 31 – Feb 3, 2023

On-site housing and meal plan are additional and available at discounted rates through the FSFC. (352) 369-2818

Participant Registration

Participant Information

Participant #2

Participant #3

Participant #4

Participant #5

Medical Team Specialist Course
Jan 31 – Feb 3, 2023