Trauma Camp Participant Registration

Want to know more information about Trauma Camp before you register? Click here!

Complete the following form to register as a PARTICIPANT for Trauma Camp. 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

First Name

Last Name

Date of Birth

YYYY

PSID

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

(###)

###

####

Email Address

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Firefighter Certification

EMS Certification

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.

Yes - Tent

Yes - Camper or RV

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

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Phone Backup

(###)

###

####

Allergies

Current Medications

Medical History

DEPARTMENT OR AGENCY INFORMATION

Fire Department or Agency

Name of Chief or Supervisor

First Name

Last Name

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.

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