Sunday, April 20, 2014
     
 
Marion County EMS         202 S 3rd St, Ste B          Marion, KS 66861-1659          620-382-3271
PLEASE TYPE OR PRINT
Sponsoring Organization: MARION COUNTY EMERGENCY MEDICAL SERVICE  
Program Managers Name:     Phone:    
Address:   City:     State: KS Zip: 66861  
Medical Director: Shauna Kern, D.O.            
Class Location, Building:   Address:  
City:     State: Ks. Zip:     EMS Region III
This program is open to attendants outside of your agency? Yes   No  
Is this class submitted for educational incentive grant funding? Yes   No x
Complete the schedule on the back of this form and must be received at least 15 days prior to
beginning the continuing education program. If there are any schedule changes necessary,
notify Marion County EMS in writing.
THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF
MY KNOWLEDGE.
           
Signature of Applicant Date
                       
Marion County EMS Use Only
This proposed schedule:   is approved   is not approved
Course Identification Number: #PP-3271
Amount of continuing education credit awarded:    
           
Approved by Date
 
 
 
Sponsoring Organization: Marion County EMS  
Program Managers Name:     Phone:    
Address:   City:     State: KS Zip:    
Medical Director: Shauna Kern, D.O.            
Class Location, Building:   Address:  
City:     State: Ks Zip:     EMS Region III
This program is open to attendants outside of your agency? Yes   No  
Is this class submitted for educational incentive grant funding? Yes   No x
Complete the schedule on the back of this form and must be received at least 15 days prior to
beginning the continuing education program. If there are any schedule changes necessary,
notify Marion County EMS in writing.
THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF
MY KNOWLEDGE.
           
Signature of Applicant Date
                       
Marion County EMS Use Only
This proposed schedule:   is approved   is not approved
Course Identification Number: #PP-3271
Amount of continuing education credit awarded:    
           
Approved by Date

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