PCIS 33: Jefferson County Pre-registration form Survey

May 18th - 20th, 2026

**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.

1.Full Name - This will go on the training certificate(Required.)

First name

Last name

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

Fist name

3.Address(Required.)

Address

City/Town

State/Province

ZIP/Postal Code

4.Department/Agency(Required.)

5.I am a:(Required.)

6.Mobile phone, dashes are helpful (do not use office phone or someone else's number)(Required.)

(xxx) xxx-xxxx

7.Email address (Do NOT use Dept/Agency email)(Required.)

8.Any dietary restrictions?(Required.)

9.Very briefly describe the critical incident(s) that you find most challenging, or that you find yourself thinking of most often? Please don’t list “20+ years”, or “everything”, etc. A very brief example(s) helps us with logistics. Thank you.(Required.)

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, so that we may have their information as well.(Required.)

Yes

11.Emergency Contact information (someone not in attendance).(Required.)

Name

Phone Number