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?W 4 <br />FORM M: EDUCATION PROGRAM REQUEST FORM <br />This folm is required on ALL education and training projects <br />If our 2W _O"/ Includes a r-equest for education and/or training, com /ete this form. If your proposal does not <br />include a request for education and training do not include this form in your proposal packet. <br />For multiple entity proposals complete an Education Program form for each entity for which education and/or <br />training funds are requested. <br />If your request includes reimbursement of certification or card course tuition, complete this <br />ortion. <br />1. Projected number of students EMD- <br />in each certification course. EMT r' EMT-l EMT-P EMD Instructor <br />BTLS/ <br />CPR ACLS _ PALS _ PEPP PHTLS NALS CISM <br />Other course(s), not listed above. List name of <br />course and projected number of students: 4 91 'fat rfA K55 E W T` I N <br />2. Participating organizations: ^,- WARwS t?A VQ V RA g S - <br />3. Are the prospective students currently involved with patient care: Yes ? No <br />4. What measures will be taken to ensure students will be involved in Pre-Hospital Emergency Care following <br />successful course completion? T w,1% 6-" <br />5. What measures will be taken to ensure students maintain achieved certification? <br />#? tAc_` G1?k t ? S C dlr5 S <br />&J& S All <br />B <br />. If your request includes continuing education, describe the CE program: <br />If your request includes reimbursement for conducting an EMS course or EMS-related <br />courses , corn lets thisortion. <br />1. List name of course(s), number of students and frequency of offering during this grant period: <br />2. Do you expect to offer this course after the grant period? ? Yes ? No <br />If yes, explain the long-range plans for course offering(s), <br />3. if your request includes purchase of training equipment, what entity will retain possession/responsibility of <br />equipment during grant period? <br />4. If your request includes purchase of training equipment, what are your plans for this equipment after this grant <br />period (long-range plans)? <br />5. Are the prospective students currently involved with patient ? Yes ? No <br />care: <br />6. What measures will be taken to ensure students will be involved in Pre-Hospital Emergency Care following <br />successful course completion? <br />?. What measures will be taken to ensure that students maintain achieved training/certification?