Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastDepartment / Agency *Email *EmailConfirm EmailAddress *City *County *State *Zip Code *Date of Birth *Contact #Program you are registering for: *Farm Rescue Training - East Prospect - 6/2/23Grain Bin Rescue Awareness - Letterkenny FD #1 - 6/7/23Grain Bin Rescue Awareness - Letterkenny FD #2 - 6/8/23Grain Bin Rescue Awareness - Shamokin - 6/10/23Silo Fire & Emergency Awareness - Leduc County - 6/22/23Farm Emergency Awareness - Beaver County - 6/24/23By signing below, I certify that I am a bona-fide member of my agency/department and is covered by workman’s compensation and liability coverage by this agency. RescueTechs LLC, the program instructors, and the host agency (if other than my own) assume no liability for injuries or deaths that occur as part of this training program. Please put your initials in the text field below to acknowledge.Signature *Clear SignatureSubmit