Infant Safe Sleep Certification Program Enrollment Form

Enrolling EMS Agency or Fire Department Information

The Infant Safe Sleep Certification Program is an education program and suite of resources for EMS Agencies and Fire Departments. Complete the enrollment form to enroll your EMS Agency or Fire Department in the Program.

Question Title

* 1. EMS Agency or Fire Department Name (use your official and complete name)

Question Title

* 2. Agency/Department Address

Address:

City:

State:

Zip code:

Question Title

* 3. If different from the address above, enter your mailing address to receive a mailed resource packet:
(This question is optional. Please skip if it doesn't apply.)

Address:

City:

State:

Zip code:

Question Title

* 4. Select all the counties your agency/department serves:

Alcona

Alger

Allegan

Alpena

Antrim

Arenac

Baraga

Barry

Bay

Benzie

Berrien

Branch

Calhoun

Cass

Charlevoix

Cheboygan

Chippewa

Clare

Clinton

Crawford

Delta

Dickinson

Eaton

Emmet

Genesee

Gladwin

Gogebic

Grand Traverse

Gratiot

Hillsdale

Huron

Houghton

Ingham

Ionia

Iosco

Iron

Isabella

Jackson

Kalamazoo

Kalkaska

Kent

Keweenaw

Lake

Lapeer

Leelanau

Lenawee

Livingston

Luce

Mackinac

Macomb

Manistee

Marquette

Mason

Mecosta

Menominee

Midland

Missaukee

Monroe

Montcalm

Montmorency

Muskegon

Newaygo

Oakland

Oceana

Ogemaw

Ontonagon

Osceola

Oscoda

Otsego

Ottawa

Presque Isle

Roscommon

Saginaw

St. Clair

St. Joseph

Sanilac

Schoolcraft

Shiawassee

Tuscola

Van Buren

Washtenaw

Wayne, including City of Detroit

Out Wayne County Only

City of Detroit Only

Wexford

Other (please specify)

Question Title

* 5. Number of EMS and/or Fire personnel on staff at your Agency/Department?

Question Title

* 6. Does your agency have a Community Integrated Paramedicine Program?

Yes

Infant Safe Sleep Certification Program Enrollment Form

Enrolling EMS Agency or Fire Department Information

Question Title

* 1. EMS Agency or Fire Department Name (use your official and complete name)

Question Title

* 2. Agency/Department Address

Question Title

* 3. If different from the address above, enter your mailing address to receive a mailed resource packet: (This question is optional. Please skip if it doesn't apply.)

Question Title

* 4. Select all the counties your agency/department serves:

Question Title

* 5. Number of EMS and/or Fire personnel on staff at your Agency/Department?

Question Title

* 6. Does your agency have a Community Integrated Paramedicine Program?

* 3. If different from the address above, enter your mailing address to receive a mailed resource packet:
(This question is optional. Please skip if it doesn't apply.)