In-person CAPCE

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Crisis Medicine Course taken *

Please select ONE Crisis Medicine course. The course you select will reflect the CEH uploaded to CAPCE so please ensure it is accurate

National EMS-ID (NSEMSID)

Please see https://www.nremt.org/rwd/public/document/news-ems-id-release if you are not familiar with this new recertification number. If you do not have this number, we CAN still award CEH if you complete the information below.

Student's Medical Credential License State *

Please select the state of your medical licensure, EMR, EMT, Paramedic, etc.

Student's State License Type (select from the list)

License Type - per CAPCE only one license type may be credited with each course (so you cannot submit two forms to count CEH for both paramedic & ACP for example).

Student's State Medical Credential License Number *

Please enter your STATE/National Registry license number. Entries without the completed information cannot be uploaded to CAPCE.

Student's State License Expiration Date

Please enter the month, day, and year of expiration. Entries without the complete information cannot be uploaded to CAPCE. Example 03/30/2022 BEGIN BY ENTERING THE YEAR TO ACCESS ALL DATE/MONTH COMBINATIONS

Student’s NREMT certification number

Student's NREMT Re-registration date

Please enter the month, day, and year of expiration. Entries without the complete information cannot be uploaded to CAPCE. Example 03/30/2022

I understand that Crisis Medicine as a requirement of CAPCE accreditation will submit a record of my course completions to the CAPCE AMS. I further understand that my course completion records may be accessed by or shared with such regulators as state EMS offices, training officers, and NREMT on a password-protected need-to-know basis. In addition, I understand that I may review my record of CAPCE accredited course completions by contacting CAPCE. *

I agree to the CAPCE reporting requirement

By checking this box I affirm that I participated in the full program, attending all sessions, in compliance with CAPCE requirements for submitting for continuing education credits, and am entitled to claim credit for this educational program. *

I agree

By entering my name and checking the above box, I agree to the above CAPCE terms and affirm the information I have provided is correct. *

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In-person CAPCE

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