Activity Application

name

certification number

state/ NREMT

additional Participants who will collaborate on this Activity (each is also required to submit this form independently)

activity type

activity description

I understand that Rykerr Medical LLC, 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 also understand that various members of the Rykerr Medical Program Committee may be involved in reviewing both this Activity Application and the final submission. Disclosures of potential conflicts of interest and resumes/ bios for all Program Committee members can be reviewed on the Rykerr Medical website: www.rykerrmedical.com/members

I agree that the participant(s) listed on this application will be responsible for the development of the content as outlined above. In addition, it is understood that content will be developed for the purpose of this Activity (i.e. credit will not be awarded after-the-fact for content developed on behalf of another program).

Thanks friend! The fine folks at Rykerr Medical will be in touch soon!

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