Course Cancellation or Rescheduling Claim

Name of the registered participant
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Required First Name Required Last Name
Phone *
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Email *
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Course Start Date *
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dd-MMM-yyyy
Are you requesting a: *
N/A
Reason for the Cancellation / Rescheduling: *
N/A
Medical Certificate
N/A
Upload file
Please upload the completed medical certificate if this is related to a medical condition prohibiting you from attending the course.
Death Certificate
N/A
Upload file
Please upload a copy of the death certificate if this claim is related to a death.
Proof of Service
N/A
Upload file
Please upload proof of jury duty, or proof from your employer that you were the only employee able to work causing the claim if related to essential work.
Terms and Conditions *
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By submitting this application, you confirm that you have submitted all documentation accurately to the best of your knowledge, understand that additional supporting information may be required to complete your claim, and that the decision related to approving or denying your claim rests solely on the administration of Superior EMS.

I accept the Terms and Conditions.
Signature *
N/A

E-Signature Field
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