EMR Course Application

EMR Course Application

Please fill out the questions below to your best ability.
Name:*

Legal First NameLegal Last Name
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
How do you want us to contact you?*

EmailPhone CallText Message
How did you hear about us?:*
Home Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Desired Training Facility:*
Select one that is closest to you.
Prior to this class, what medical experience do you have?:*

Fire DepartmentCPR/AEDHigh School AnatomyCNANo Experience
Are you 18-years-old or older?*

YesNo
Do you plan on working for Elite after the EMR Course?*

YesNo
Are you willing to undergo a criminal background check*

YesNo
Full/Part Time Employment?*
If last question was answered, "yes".
Do you have a valid driver's license?*

YesNo
Do you have LESS THAN 2 negative moving violations in the past 3 years?*

YesNo
Can you provide a copy of your High School Diploma, GED, or Transcript for this course?*

YesNo
Are you willing to undergo a criminal background check upon registration?*

YesNo
Front of Driver's License*
Back of Driver's License*
High School or GED Diploma
Privacy Policy

Notice: Elite Medical Transportation, LLC will not sell or give your personal information to any third-party company, person, and/or entity.
Terms & Conditions

By agreeing to these terms & conditions, you understand that submitting this form does not grant automatic entry into Elite Medical Transportation, LLC's Emergency Medical Responder Program. By agreeing to these terms & conditions, you also acknowledge that you must be at least 18-years-old or older by the time you start the Emergency Medical Responder course and that you have a Highschool diploma or GED. Also by agreeing to these terms, you understand that this course is $200.00 USD, which is only refundable after 90-days of successful licensed employment as an Emergency Medical Responder with Elite Medical Transportation, LLC.
Agreement*

I agree to these terms & conditions.
Should be Empty:

EMR Course Application

Privacy Policy

Terms & Conditions