Indiana November 2024 Event November 18-21 Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneCrossroads Emergency ConferencePlease Identify Your Primary Clinical Scope of Practice *Emergency Medical ResponderAdvanced Practice Registered NurseEmergency Medical TechnicianEMS StudentAdvanced EMTNursing StudentParamedicRegistered NurseCommunity ParamedicOtherCommunity EMTThis would be the scope of practice you feel is your primary work or knowledge.Please Identify Any Secondary Clinical Scope of Practice *Emergency Medical ResponderAdvanced Practice Registered NurseEmergency Medical TechnicianEMS StudentAdvanced EMTNursing StudentParamedicRegistered NurseCommunity ParamedicOtherCommunity EMTCheck all that apply.RN/APRN License NumberClinical Scope of Practice - Other *Please clarify "other."Total Years of Experience in the Healthcare Profession *Select0-56-1011-1516-2021-2526-3031-4041 or moreWhat Is Your Highest Level of Academic Education? *SelectDiplomaCertificate/LicensureAssociatesBaccalaureateMaster'sDoctorateCurrent undergraduate studentAssociation Membership *I am an Indiana EMS Association MemberI am not a member of either associationI am an Indiana ENA MemberI am an unlicensed nursing studentI am a member of both Indiana EMSA and Indiana ENAI am an EMS studentNAMIHP MemberENA Member NumberENA Chapter *SelectChapter 131: Big Red RoadrunnersChapter 133: SNAPChapter 134: Indy RoadrunnersChapter 137: River City RoadrunnersChapter 246: Northwest IndianaChapter 365: Northeast IndianaChapter 401: Wabash Valley RoadrunnersChapter 448: East Central IndianaChapter 474: Southwest TrailblazorsChapter 501: West CentralPrimary Employer Type *SelectConsultantEmergency Medical Service or Flight ServiceHospital or Medical FacilityRetiredSchool, College, or UniversityOther The Is Healthcare Please Specify *Emergency Medical Service or Flight Service Name *Hospital or Facility Name *SelectAscension St. Vincent EvansvilleAscension St. Vincent Indianapolis HospitalAscension St. Vincent CarmelAscension St. Vincent CastletonAscension St. Vincent AvonAscension St. Vincent KokomoAscension St. Vincent Neighborhood Hospital Indianapolis SouthAscension St. Vincent Neighborhood Hospital NoblesvilleAscension St. Vincent Neighborhood Hospital PlainfieldBaptist Health FloydBluffton Regional Medical CenterClark Memorial HospitalColumbus Regional HospitalCommunity Heart And Vascular HospitalCommunity HospitalCommunity Hospital AndersonCommunity Hospital EastCommunity Hospital NorthCommunity Hospital SouthCommunity Howard Regional HealthDanville Hospital Main CampusDaviess Community HospitalDeaconess Gateway HospitalDeaconess Midtown HospitalDeaconess Gibson HospitalDupont HospitalElkhart General HospitalEskenazi Health (Sidney and Lois Eskenazki Hospital)Fairbanks HospitalFranciscan Health CarmelFranciscan Health CrawfordsvilleFranciscan Health Crown PointFranciscan Health Dyer CampusFranciscan Health HammondFranciscan Health IndianapolisFranciscan Health Lafayette CentralFranciscan Health Lafayette EastFranciscan Health Michigan CityFranciscan Health Mooresville CampusFranciscan Health MunsterGood Samaritan HospitalGoshen HospitalHancock Regional HospitalHenry Community HealthHighpoint HealthIU HealthIU Health Arnett HospitalIU Health Ball Memorial HospitalIU Health Bedford HospitalIU Health Blackford HospitalIU Health Bloomington HospitalIU Health Frankfort HospitalIU Health Jay HospitalIU Health Methodist UniversityIU Health MorganIU Health North HospitalIU Health Paoli HospitalIU Health Saxony HospitalIU Health Tipton HospitalIU Health University HospitalIU Health West HospitalIU Health White Memorial HospitalJohnson Memorial HospitalKing's Daughters' Hospital & Health ServicesKosciusko Community HospitalLa Porte HospitalLogansport Memorial HospitalLutheran Health Network The Orthopedic HospitalLutheran HospitalMarion General HospitalMemorial HospitalMemorial Hospital and Health Care CenterMethodist Hospitals - Northlake CampusMethodist Hospitals - Southlake CampusMHP Medical CenterMonroe HospitalOrthoIndy HospitalParkview DeKalb HospitalParkview Hospital RandalliaParkview Huntington HospitalParkview Noble HospitalParkview Ortho HospitalParkview Regional Medical CenterParkview Whitley HospitalPeyton Manning Children's HospitalPinnacle HospitalPlymouth Medical CenterPMC Regional HospitalPortage HospitalPorter Regional HospitalReid HospitalRichard L. Roudebush VA Medical CenterRiley Hosptial for Children at IU HealthRiverview Health Noblesville HospitalRiverview Health Westfield HospitalSaint Catherine HospitalSaint Joseph Health Mishawaka Medical CenterSaint Joseph HospitalSaint Mary Medical CenterSaint Vincent AndersonSaint Vincent Fishers HospitalSaint Vincent Women's HospitalSchneck Medical CenterStarke HospitalTerre Haute Regional HospitalThe Heart HospitalThe Women's HospitalUnion Hospital Terre HauteUnion Hospital ClintonUnity Medical and Surgical HospitalVA Northern Indiana Health Care System - Fort Wayne CampusWitham Memorial HospitalWabash General HospitalOtherDepartment *School, College, or University Name *SelectAnderson UniversityBall State UniversityBethel UniversityChamberlain UniversityFortis CollegeGoshen CollegeHuntington UniversityIndiana State UniversityIndiana University Purdue University ColumbusIndiana University BloomingtonIndiana University EastIndiana University Fort WayneIndiana University IndianapolisIndiana University KokomoIndiana University NorthwestIndiana University South BendIndiana University SoutheastIndiana University Purdue University IndianapolisIndiana Wesleyan UniversityIndiana Wesleyan University-MarionIvy Tech Community CollegeMarian UniversityPurdue University GlobalPurdue University NorthwestPurdue University West LafayettePurdue University NorthwestSaint Mary’s CollegeSaint Mary-of-the-Woods CollegeSt. Elizabeth & University of Saint Francis CooperativeUniversity of EvansvilleUniversity of IndianapolisUniversity of Saint FrancisUniversity of Southern IndianaValparaiso UniversityVincennes UniversityWestern Governors UniversityOtherPlease Specify *Registration QuestionsDo You Participate, in Any Way, in the Evaluation of Products, Equipment, or Services?NoYesWhat Is Your Role in the Purchase of Products, Equipment, or Services? *SelectFinal decision makerSpecify or recommend productsEvaluate productsNo role in purchaseDo You Have A Dietary Restriction?NoYes, ReligiousYes, VegetarianYes, VeganYes, OtherDietary Restriction - Please Elaborate *Do You Have A Food Allergy?NoYesFood Allergy - Please Elaborate *Do You Have Accessibility Needs?NoYesAccessibility Needs - Please Elaborate *How did you find out about the symposium? *Indiana ENA WebsiteSocial Media (Facebook, X, etc.)Indiana EMSA WebsiteColleagueIndiana ENA EmailAn Indiana ENA MemberIndiana EMSA EmailAn Indiana EMSA MemberSupervisorOtherNAMIHP Communication or WebsiteChoose all that apply.Attendee OptionsOpt-Out of The Attendee DirectoryI Choose to Opt-Out of The Attendee Directory.Attendee Directory Opt-Out Check this box if you do not want to have your name and contact information included in the attendee directory. The directory is only provided to event attendees to facilitate networking and is not used for direct or indirect solicitation purposes.Opt-Out of The Sponsor DirectoryI Choose to Opt-Out of The Sponsor Directory.Sponsor Directory Opt-Out Check this box if you do not want to have your registration information (including name, email, and postal address given) included in the list above for event sponsors for purchase.Registration TypeIdentify your role (if any) in the conference: AttendeeAttendee - Part of the Planning CommitteePresenter - First or Primary Presenting AuthorPresenter - Co or Secondary Presenting AuthorAttendee - I wish to attend the conference as a participant. Attendee - Part of the Planning Committee - I serve on the Planning Committee for this conference and am attending the scheduled meetings. Presenter - First or Primary Presenting Author - I submitted an abstract for the conference and was accepted. I am listed as the lead author on the submission. Presenter - Co or Secondary Presenting Author - I am listed as a co-author on an abstract and I may be presenting at the conference. If you are attending the Crossroads Emergency Conference, which day will you be attending lunch?Day 1 - November 21, 2024Day 2 - November 22, 2024If you are attending the Crossroads Emergency Conference, do you plan to attend the evening mixer on day one, Thursday, November 21, 2024?Yes, Add Mixer Ticket Item, November 21, 2024 - $30.00CP-C Bootcamp Indiana Emergency Nurses Association BootcampNov 19, 2024, 8:00 AM French Lick Springs HotelCP-C Bootcamp TicketCP-C Bootcamp Student - $749.00 Ticket Details Acknowledge *I hereby acknowledge that I will be prompt and in attendance to my exam on Tuesday November 19, 2024, at 1:00 PM.Please indicate that you’ve read and agree to the event’s policies. *I agree to Cancellation Policy, Refund Policy, Terms & ConditionsPolicy Submit