If FDIC were to obtain a monitor/defibrillator for use during the competition, please select the monitor brand and model that you prefer below (note that Physio-Control LifePak 12 and Phillips mRX monitors may be used, but can't be obtained by FDIC).* Zoll X-SeriesPhysio Control LifePak 15Other

If other, please specify:

Team Leader First Name

Team Leader Last Name

Team Leader Certification ALSBLS

Team Leader Title

Team Leader Organization

Team Leader Cell Phone

Team Leader Email

Team Member #1 First Name

Team Member #1 Last Name

Team Member #1 Certification ALSBLS

Team Member #1 Title

Team Member #1 Organization

Team Member #1 Cell Phone

Team Member #1 Email

Team Member #2 First Name

Team Member #2 Last Name

Team Member #2 Certification ALSBLS

Team Member #2 Organization

Team Member #2 Title

Team Member #2 Cell Phone

Team Member #2 Email

Team Member #3 First Name

Team Member #3 Last Name

Team Member #3 Certification ALSBLS

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Team Member #3 Organization

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Team Member #3 Email

Alternative Team Member First Name

Alternative Team Member Last Name

Alternative Team Member Certification ALSBLS

Alternative Team Member Title

Alternative Team Member Organization

Alternative Team Member Cell Phone

Alternative Team Member Email

Has your department ever competed in the JEMS Games before? YesNo

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