Registration Form

Please read the brochure before filling out the registration form.  The brochure will answer important questions like times, dates, travel information and who is eligible to attend. C.O.P.S. Hands-On Program

Retreat you are attending
First Name
Last Name
Address
City
State
Zip Code
Home Phone
Cell Phone
Email Address
Birthday

Others attending with you

(if your spouse or children are attending, please sign them up here)

Must list their birthday(s)
Any medical condition we should know about?
TRAVEL INFORMATION
We will be flying or driving
Arrival Date (dd/mm/yy)
Airline
Flight Number
Arrival Time
Departure Date (dd/mm/yy)
Airline
Flight Number
Departure Time
OFFICER'S INFORMATION
Fallen Officer's Name
Date of Death (dd/mm/yy)
Department
Accident or Felony
EMERGENCY INFORMATION
Your Health Carrier
Policy Number
Name to call in case of emergency
Relationship
Home Phone
Cell Phone
Additonal Comments