Trauma Camp Registration

Complete the following form to register for Trauma Camp 2017.  All fields are required.

All Trauma Camp participants must be associated with a public safety agency for insurance purposes.

Indiana Residents: An Indiana Public Safety Identification Number (PSID) is required to participate in Trauma Camp.

If you do not have a PSID , go to http://www.in.gov/dhs/3880.htm and request a PSID.  In the PSID box on the form below, type "requested", and proceed with completing your registration.  One week after submission we will verify that a PSID has been issued to you.  If you do not have a PSID when Trauma Camp begins, you will not be allowed to participate.

If you live in a state other than Indiana, in the PSID box on the form below type the name of the state followed by your state-issued identification number.

 
PERSONAL INFORMATION
Name *
Name
Date of Birth *
Date of Birth
If you have requested a PSID on the Indiana DHS website but have not received it yet, type "requested" and proceed with completing your registration. If you live in a state other than Indiana, type the name of the state followed by your state-issued identification number.
Phone *
Phone
Home Address *
Home Address
Do you plan to camp on Friday and/or Saturday night? *
You can change your mind later, this is just to give us an idea of how many people are planning to stay overnight.
EMERGENCY INFORMATION
The information provided in this section is for use in case of an emergency and will be utilized only by Trauma Camp administrators and medical staff involved in your care should an emergency occur.
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Emergency Contact Phone Backup
Emergency Contact Phone Backup
DEPARTMENT OR AGENCY INFORMATION
Name of Chief or Supervisor *
Name of Chief or Supervisor
Chief or Supervisor Phone Number *
Chief or Supervisor Phone Number
CONFIRMATION
By checking this box and submitting this registration form, I certify that the information I have provided on this form is true, accurate, and complete. *