<p> EMS Scholarship Qualifying Questionnaire 2013 Comprehensive Update: Stroke and Neurocritical Care</p><p>Prefix Mr. Mrs. Miss Ms. Dr. Prof</p><p>First Name </p><p>Middle Name </p><p>Last Name Credentials/Certifications</p><p>(ex. EMT, EMT-P, etc.) Email (REQUIRED) * An account will be created for you on The Ohio State University Center for Continuing Medical Education website (http://ccme.osu.edu). An electronic record of your CME certificate for this conference will maintained up to six years. You will log on to this website to retrieve your CME certificate. Address 1 </p><p>Address 2 </p><p>City State </p><p>Zip Country </p><p>Phone ( ) Fax ( ) Job Classification/Title (ex. EMS Coordinator, </p><p>Teaching Captain, Firefighter, etc) EMS Agency (ex. department, station number, etc.)</p><p>What population/area do you serve?</p><p>Briefly describe why you feel you should be selected to receive this scholarship? (Maximum of 200 words)</p><p>EMS Scholarship Qualifying Questionnaire (cont.)</p><p>If I am chosen for the scholarship, I plan to attend:</p><p>Full Conference (Oct 10 & 11) Thursday ONLY (Oct 10) Friday ONLY (Oct 11)</p><p>For planning purposes, if you plan to attend the conference on Friday, October 11, please select ONE talk from each Concurrent Session below:</p><p>Concurrent Session Selection (PLEASE SELECT ONE FROM EACH SECTION BELOW)</p><p>Concurrent Session #1 A – Intravenous Thrombolysis: Beyond NINDS B – Stroke and Hemicraniectomy C – Stroke Rehabilitation IP and after Discharge I will not be attending this concurrent session.</p><p>Concurrent Session #2 A – Update in the Management of Intracerebral Hemorrhage B – Update in Stroke Prevention C – Stroke Mimics I will not be attending this concurrent session.</p><p>Concurrent Session #3 A – Childhood Stroke B – Update in the Surgical Management of Intracranial and Extracranial Vascular Stenosis and Dissection C – Hospital Stroke Certifications I will not be attending this concurrent session.</p><p>Concurrent Session #4 A – Women and Stroke/Stroke in Pregnancy B – Cryptogenic Stroke C – Update in the Management of Subarachnoid Hemorrhage I will not be attending this concurrent session.</p><p>Concurrent Session #5 A – Telemedicine and Stroke B – Spasticity Options in Stroke Care C – New Drugs Impacting Stroke Patients I will not be attending this concurrent session.</p>