Reservation Request for LCD Projector

* Required Fields

Name     (first)     *       (last)     *  

Address   (street)    *   

               (city)     *     (zip code)      *  

Home Phone     *        Cell Phone   

Course Name     *   

Course Date       *  

Course Location      *  

Date of Checkout      *       Date of Return      *  

Use of the Regional Council LCD Projectors is on a first come, first serve basis. Priority will always be given to Office of EMS functions and conferences, Council functions, and then to certification classes within the region. Council Staff, Board of Directors Members, Committee Chairpersons, and certified EMS Instructors within PEMS are eligible to use the projectors. The person on this document will also be responsible for any damage that results from carelessness or misuse. The PEMS Council Staff will be glad to instruct you in the setup and use of the projector. With rare exceptions, the checkout period for the projectors will be one week.

I, the above, accept all responsibility listed here     yes        no