KDEM Course Request Form

2. This form should be used for any course request including State and Federal delivery courses. When complete, send to your County Emergency Manager, who will determine approval and forward to the State Training Officer. You will be contacted by KDEM to confirm the course request.

4. Name*
5. Email Address*
7. Agency/Organization*
8. Address*
10. City*
11. Zip Code*
13. Phone Number*
14. Cell Number
16. Your County Emergency Manager's Name:*
17. Local Point of Contact

    (If different than requesting agent)

19. Local POC Phone Number
20. Local POC Email Address
24. Course Information
26. Course Code
27. Course Name
29. Course Date*
    Course Date Start Date

    —

    Course Date End Date
30. Alternate dates if desired
32. Course Venue*

    (Location or building name)

33. Room Name or Number
35. Address*
37. City*
38. County*
39. Zip Code*
41. Class max capacity
42. Additional information

    (Example: Have booked instructor, parking directions, amenity Information or anything else to show on the “Details” page in the registration site)

46. After KDEM receives the completed Request Form, the State Training Officer will contact your County Emergency Manager for confirmation/arrangements. The State Training Officer will then contact the Requesting Agent to confirm the request and continue arrangements.
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

* indicates a required field