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 - What is your national or state certification number?

Team Leader Title

Team Leader Organization

Team Leader Cell Phone no dashes; numeric values only

Team Leader Email

Team Member #1 First Name

Team Member #1 Last Name

Team Member #1 Certification ALSBLS

Team Member #1 What is your national or state certification number?

Team Member #1 Title

Team Member #1 Organization

Team Member #1 Cell Phone no dashes; numeric values only

Team Member #1 Email

Team Member #2 First Name

Team Member #2 Last Name

Team Member #2 Certification ALSBLS

Team Member #2 What is your national or state certification number?

Team Member #2 Organization

Team Member #2 Title

Team Member #2 Cell Phone no dashes; numeric values only

Team Member #2 Email

Team Member #3 First Name

Team Member #3 Last Name

Team Member #3 Certification ALSBLS

Team Member #3 What is your national or state certification number?

Team Member #3 Title

Team Member #3 Organization

Team Member #3 Cell Phone no dashes; numeric values only

Team Member #3 Email

Alternative Team Member First Name

Alternative Team Member Last Name

Alternative Team Member Certification ALSBLS

Alternative Team Member - What is your national or state certification number?

Alternative Team Member Title

Alternative Team Member Organization

Alternative Team Member Cell Phone no dashes; numeric values only

Alternative Team Member Email

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

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