PCIS 28: Buffalo Pre-registration form

August 11 -13th, 2025

**In the upcoming weeks, NYLEAP will contact you by phone to confirm your registration and provide specific details such as location address**

Participants are responsible for reserving and paying for their own hotel accommodations (if needed); and are encouraged to stay at the designated PCIS hotel.

Upon confirmation by phone, we will provide hotel contact information where reservations can be made directly with the hotel at the negotiated rate. This includes breakfast. Departments/Agencies are asked to cover the cost of travel/lodging for their personnel. Lunch/dinner are provided at no cost during PCIS. NYLEAP is a 501(c)(3) Nonprofit organization.

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* 1. Full Name - This will go on the training certificate

First name

Last name

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* 2. Please list if you go by another name (We will put this on your name tag)

Fist name

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* 3. Address

Address

City/Town

State/Province

ZIP/Postal Code

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* 4. Department/Agency

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* 5. I am a:

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* 6. Mobile phone

Phone Number

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* 7. Email address (Do NOT use Dept/Agency email. Dept/Agency emails can be subpoenaed)

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* 8. Any dietary restrictions?

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* 9. Briefly describe the critical incident(s) in which you were involved? (e.g., fatal shooting, serious child abuse cases, traffic accident fatalities, etc.).

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* 10. We strongly encourage your significant other to attend. Please answer yes/no if your significant other is attending. Please have them fill out this form separately.

Yes

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* 11. Emergency Contact information

Name

Phone Number