REQUEST FOR “PORTABLE” TRIAGE COURSE PACKET
From Massachusetts ENA State Council
Date ___________________
Name of sponsoring group:
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Contact person (Coordinator):
______________________________________________
Address: _______________________________________________________
_______________________________________________________
Phone number: ___________________________________________________
E-mail Address:
__________________________________________________
Date(s) of course:
______________________________________________________
Location/ Address of course:
______________________________________________
_________________________________________________________
Target audience/area:
___________________________________________________
Expected number of participants:
___________________________________________
Special needs/comments/questions:
_________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Please return request to: Robin Walsh
76 Cushman Rd
Leverett, MA 01054
Rwrn627@aol.com
(413)549-9139