EMT Course Registration Form

1
Student Name* This field is required.
First Name
Middle Name
Last Name
2
Birth Date* This field is required.
Month
Day
Year
3
LAST 4 SSN* This field is required.IF NO SSN TYPE N/A
4
Gender* This field is required.M, F, X
Please Select
Please Select
Male
Female
N/A
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
County (Not Country)* This field is required.Example: Bronx, Kings, Queens, New York, Westchester, Putnam, Dutchess, Rockland
7
Student E-mail* This field is required.
8
Mobile Number* This field is required.DEMO: ### #######
Area Code
Phone Number
9
State Photo ID* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
10
EMT Course Start Dates* This field is required.Choose Your Desired Start Date
Please Select
Please Select
Bronx - Hybrid Original EMT Evening - 09/08/25 - 12/18/25 - M,T,W,TH, Some F - 6:00PM-9:30PM
Brooklyn - Hybrid Original EMT Evening - 09/08/25 - 12/18/25 - M,T,W,TH, Some F - 6:00PM-9:30PM
Manhattan - Hybrid Original EMT Evening - 09/08/25 - 12/18/25 - M,T,W,TH, Some F - 6:00PM-9:30PM
Poughkeepsie - Hybrid Original EMT Evening - 09/08/25 - 12/18/25 - M,T,W,TH, Some F - 6:00PM-9:30PM
Bronx - Hybrid Original EMT Afternoon - 09/29/25 - 12/18/25 - M,T,W,TH, Some F - 10:00AM-2:30PM
Brooklyn - Hybrid Original EMT Afternoon - 09/29/25 - 12/18/25 - M,T,W,TH, Some F - 10:00AM-2:30PM
Poughkeepsie - Hybrid Original EMT Afternoon - 09/29/25 - 12/18/25 - M,T,W,TH, Some F - 10:00AM-2:30PM
Bronx - Challenge Refresher - 10/05/25 - 12/18/25 - Sundays - 10:00AM - 6:00PM
11
Payment Option* This field is required.
Option A ($1300.00) Includes Tuition, 2 Uniform Shirts, 1 Patch, Digital Textbook (Payment Plans Available)
Option A ($1300.00) Includes Tuition, 2 Uniform Shirts, 1 Patch, Digital Textbook (Payment Plans Available)
Option B ($1500.00) Includes Tuition, Textbook, Equipment, 2 Uniform Shirts, 1 Patch, Digital Textbook
Option C ($1625.00) - TextBook, Digital Textbook, CPR Digital TextBook, Equipment, & 3 Uniform Shirts, 1 Patch, 2 Pants, Boots
Option D / Accelerated Option - $1700.00 - Includes TextBook, Flash Card Book, Stethoscope, Blood Pressure Cuff, CPR Face Mask, Shears, Pen Light, O2 Key, Oximeter, 4 Uniform Shirts, 2 Uniform Pants, Boots
Refresher (Not Challenge) - $700 - Includes Textbook Digital Access - 1 Uniform Shirt
Challenge Refresher Without Voucher - $450 - Includes CPR, Textbook Digital Access
Challenge Refresher With Voucher - $450 - Includes CPR, Textbook Digital Access ($200 + $250 Security Deposit Required To Start
Transfer Student - $200 Deposit Required - Tuition Price By Request
Columbia University EMS Student
Academy Accelerated - Minimum $600 when registering. Total $1200 Deposit
12
Shirt Size
XS
Small
Medium
Large
XL
XXL
XXXL
13
Grants / Vouchers Accepted* This field is required.(Please Choose Only If It Applies To You)
None
Access VR
GI Bill
1199 Union
Home Path
Covenant House
EMS Agency Verification (Voucher)
14
How Did You Hear About Us?* This field is required.
Word Of Mouth
Facebook
Instagram
YouTube
Mall Advertisement
Job Fair
Friend or Family
From A Graduate
Walk In
Billboard
Other
15
Is this your first EMT School? If not, where did you attend prior?
16
Quick Notes For OfficeOr EMT Number If You Are A Refresher
17
Functional Job Description (Signature Required)* This field is required.Please Sign Below After Acknowledging The Following That You Are Aware Of The Basic Job Description Of EMT's: I have read and or understand the functional description of a (n) CFR/EMT/AEMT. I have no conditions which would preclude me from safely and effectively preforming all the functions of the level of CFR/EMT/AEMT for which I am seeking a New York State certification. https://www.health.ny.gov/professionals/ems/pdf/00-10.pdf
Clear
18
AMERICANS WITH DISABILITIES ACT (ADA) (Signature Required)* This field is required. Any student wishing to request an accommodation for the State written examination must contact NYS/DOH/EMS,no later than six weeks prior to the exam. You may call (518) 402-0996 for further assistance. I am aware and understand the functional job description of a(n) CFR/EMT/AEMT. I am aware IF I need to submit a request for an accommodation for the New York State Written Certification Examination. I understand that I must contact the Bureau of EMS Central Office at (518) 402-0996 no later than six (6) weeks prior to the scheduled State written examination date for this course.
Clear
19
Course Payment Description: (Signature Required)* This field is required.Course Payment Description: Students that have recently registered online for our upcoming EMT course can make their first payment online to secure their seat. (Please be advised the $200 registration deposit is NON-REFUNDABLE, but can be put towards any future class within the next 12 months) *If you do wish to make this payment online rather then at our office, an additional convenience fee will be applied to your order. *(REGISTRATION PAYMENT OF $200 IS APART OF THE TUITION) If students would like to save and not pay tax, they may complete registration on here and pay tuition payments in cash in the office. Otherwise 4% tax will be applied. (Students who pay in Full any option will receive a Free EMT Flashcard book) FAQ - Rules and Regulations For Registration: www.codeonetraining.com/emtfaq www.codeonetraining.com/emt-payment-plan *By confirming your order you are aware of the Rules and Regulations for the Emergency Medical Technician Course and its payment plan. Thank You (You may also get a shipment confirmation email, please ignore) Cash Deposits: If you are not leaving the deposit at this time, please do not submit registration. Students may come in to the office to leave a cash deposit and staff will prompt student to register on another form. Thank You
Clear
20
Card Holder ID UploadUpload ID of Card Holder Required if payer is not student named above (If this does not apply please proceed to next slide)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
21
Card Holder SignatureCard Holder Signature Required if payer is not student named above (If this does not apply please proceed to next slide)
Clear
22
Course Payments* This field is required.
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
TaxUSD
SubtotalUSD
Total costUSD
EMT Course Deposit Original or Refresher (Non Refundable)
$200.00Edit
Back
EMT Course 2nd Payment
$550.00Edit
Back
EMT Course Option A FULL Payment (Free Flash Card Book)
$1,300.00Edit
Back
EMT Course Option B FULL Payment (Free Flash Card Book)
$1,500.00Edit
Back
EMT Course Option C FULL Payment (Free Flash Card Book)
$1,625.00Edit
Back
EMT Course Option D FULL Payment (Free Flash Card Book)
$1,700.00Edit
Back
EMT Regular Refresher Course Full Payment
$700.00Edit
Back
EMT Challenge Refresher Course Full Payment
$450.00Edit
Back
Total cost $0.00
Payment Methods
Credit Card
First Name
Last Name
Cash App
After submitting the form, you will be redirected to the Cash App Pay to complete the payment process.
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
ACH Bank Transfer
Account Holder Name
Afterpay
After submitting the form, you will be redirected to the Afterpay to complete the payment process.
Should be Empty: