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Foundations of Medical Oversight Course (FOMOC)
FOMOC Host Application
Section 1: Host Information
Please complete the following information
Your Name:
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First
Last
Email:
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Phone
*
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Section 2: Course Information
Proposed Location (City, State)
This course will be...
In-person (8 hours)
Virtual (2 days for hours each)
Must be a date in the future at least 60 days from application.
Proposed Date of Course (one day)
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DD
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Proposed Date of Course (second day)
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DD
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Is this an NAEMSP State Chapter sponsored course?
Yes
No
Host Chapter:
Will your course be offered in conjunction with another conference/event?
*
Yes
No
If yes, please specify
Are you seeking any outside funding for your course offering?:
*
Yes
No
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.
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Yes
No
Course Director Name:
Please upload the resumes/CVs for the course director and any identified faculty.
*
Add File
Allows for multiple uploads.
Date
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YYYY
Electronic Signature
By checking this box I am adding my electronic signature to this form.
