Foundations of Medical Oversight Course (FOMOC) Host Application

Section 1: Host Information

Please complete the following information

Name *

First

Last

Email *

Phone *

Section 2: Course Information

Proposed Location (City, State) *

This course will be...

In-person (8 hours)
Virtual (2 days for 4 hours each)

Must be a date in the future at least 60 days from application.

Proposed Date of Course (one day)

Proposed Date of Course (second day)

Is this an NAEMSP State Chapter sponsored course?

Host Chapter:

Will your course be offered in conjunction with another conference/event? *

If yes, please specify

Are you seeking any outside funding for your course offering? *

If yes, please specify

Has a Course Director been identified? *

Requirements: Must be an active member of NAEMSP and have significant relevant experience in EMS medical oversight. Course directors must also have participated in teaching a Foundations of Medical Oversight Course with satisfactory reviews.

Course Director Name:

Please upload the resumes/CVs for the course director and any identified faculty.

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Submission Date

Electronic Signature

By checking this box I am adding my electronic signature to this form.