Post Critical Incident Seminar Registration

Post Critical Incident Seminar Registration

Please note: If you are attending on duty and at the expense of your agency, this registration form should be submitted by someone in your chain of command who has authorized the training.
Course cost: There is no course registration fee for this seminar. Once NCLEAP receives registrations, we will respond with registration confirmation to the email provided below. All participants are responsible for reserving and paying for their own hotel accommodations and are encouraged to stay at the designated PCIS hotel. Upon confirmation, we will provide hotel contact information where reservations can be made directly with the hotel at the negotiated rate. This includes breakfast. Departments are asked to cover the cost of travel/lodging/meals for their personnel.
Which seminar session are you attending?

AprilAugustNovember
Attendee Information

Please fill name and contact information of attendees.
Your Name - This will go on the training certificate.*

PrefixFirst NameLast Name
Please list if you go by another name - we will put this on your nametag
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Department/Agency*
I am a*

Sworn Law Enforcement OfficerCorrections OfficerFirst Responder - FireFirst Repsonder - EMSFirst Respsonder - TelecommunicatorOther
Preferred Email Address*
example@example.com
Preferred Contact Number
Please enter a valid phone number.
Do you have any dietary restrictions?
Briefly describe the critical incident in which you were involved. (Ex: fatal shooting of a fellow offcier, serious child abuse cases, traffic accident fatality, etc) *
We encourage your spouse to attend. Please check below if they are attending and have them fill out the questions.

Yes
Spouse Full Name - This will go on your certificate*

PrefixFirst NameLast Name
Please list if you go by another name - we will put this on your nametag
Spouse Preferred Email Address
example@example.com
Spouse Preferred Contact Number
Please enter a valid phone number.
Address - If different from your spouse

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse is

Sworn Law Enforcement OfficerCorrections OfficerFirst Responder - FireFirst Repsonder - EMSFirst Respsonder - TelecommunicatorNone of the aboveOther
Calculation
Should be Empty:

Post Critical Incident Seminar Registration

Attendee Information