What is PPMD and Good Samaritan Law Workshop - Independent Hose Co Registration
Please complete this form to pre-register for the 'What is PPMD' and 'Good Samaritan Law' workshop at the Independent Hose Company
on January 17, 2026 from 9am - 12pm.
Registration is not required to attend.
First Name
Last Name
Email
Phone
Please describe yourself
Parent/Guardian
Other relative
Student/Youth
Professional
Organization/Company Name
What is your county of residence?
Please select...
Charles
Allegany
Anne Arundel
Baltimore City
Baltimore County
Calvert
Caroline
Carroll
Cecil
Dorchester
Frederick
Garrett
Harford
Howard
Kent
Montgomery
Prince George's
Queen Anne's
Somerset
St. Mary's
Talbot
Washingon
Wicomico
Worcester
Out of state (not in Maryland)
What is your race?
(This question helps PPMD to ensure we are reaching everyone in our community and to receive grants to fund our programming.)
American Indian or Alaska Native
Asian or Asian American
Black or African American
Native Hawaiian or other Pacific Islander
White or Caucasian
Two or more races
Other
Prefer not to answer
What is your ethnicity?
(This question helps PPMD to ensure we are reaching everyone in our community and to receive grants to fund our programming.)
Hispanic or Latino
Non-Hispanic or Latino
Prefer not to answer
What is the age of your child(ren)?
What is the gender your child(ren)?
What is the race of your child(ren)?
(This question helps PPMD to ensure we are reaching everyone in our community and to receive grants to fund our programming.)
American Indian or Alaska Native
Asian or Asian American
Black or African American
Native Hawaiian or other Pacific Islander
White or Caucasian
Two or more races
Other
Prefer not to answer
What is the ethnicity of your child(ren)?
(This question helps PPMD to ensure we are reaching everyone in our community and to receive grants to fund our programming.)
Hispanic or Latino
Non-Hispanic or Latino
Prefer not to answer
Please check any disabilities your child(ren) has:
Autism
ADD/ADHD
Deaf/Blind
Developmental Delay
Intellectual Disability
Deaf/Hearing Impairment
Emotional Disability
Learning Disability
Multiple Disabilities
Other Health Impairment
Orthopedic Impairment
Speech and Language
Traumatic Brain Injury
Vision Impairment/Blind
Suspected Disability
None
Other
Please select if your child has an IEP or 504 plan
Individualized Education Program (IEP)
504 plan
None
Contact Information