NEMTAC® Course Request Form - 2026
First Name
Last Name
Phone
*
Email
*
City
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State
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Postal Code
Course Requested
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AMDS
AMDS-I
CSO
CSO-I
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Course – Number of Students
*
Course – Desired Date 1
Course – Desired Date 2
Course – Classroom Available?
*
Yes
No
Host Can Arrange
Course – Equipment Available
*
Manual Wheelchair
4-Point Tie-Down System (Straps)
Wheelchair Restraint System (Floor-mounted, track, or L-track)
Lap & Shoulder Belt Restraints
Q’Straint or Similar Docking System
Side-Entry WAV
Rear-Entry WAV
Full-Size Van with Lift
Stretcher Access Vehicle
Stretcher / Gurney (Standard Manual)
Power-Assist Stretcher / Gurney (if applicable)
Transfer Board / Slide Board
Bed or Transfer Surface Available (for safe lateral transfer)
Seatbelt Extensions / Positioning Belts
Unsure – Need Guidance
No Equipment Available
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Additional Notes
Special requests, constraints, scheduling details.
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