Course Registration Form

EMT/Paramedic Student Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Format: (000) 000-0000.
Courses
Are you currenty Active or Reserve Duty or a Veteran of the Armed Forces?
If you are applying for Paramedic program, are you a Graduate of CJCFPD EMT Program? (If applying for EMT, mark N/A)
Are you an immediate family member of a current CJCFPD employee?
What is the name of the CJCFPD employee?
Who is Your Employer (If applying for EMT, type N/A)
What is your position at the above Employer? (If applying for EMT, type N/A)
Is your employer responsible for paying the class fees? (If applying for EMT, mark N/A)
Who is your employer that will be responsible for payment? (If applying for EMT, type N/A)
Have you applied previously to the CJCFPD Paramedic Program? (If applying for EMT, mark N/A)
Please list all EMS Experience. Please include years of experience. (If applying for EMT, type N/A)
Please list all non-EMS related or all other Healthcare experience. Please include years of experience:
YesNo
If you answered yes to the above question, please describe below what those accommodations are.
Release Authorization:

* I request and authorize Central Jackson County Fire Protection District on my behalf of the information needed for entry into the Parmedic/EMT Course. I am aware and agree that this information may be shared with the clinical sites that are a required part of this educational program.

* I have reviewed the information presented on this form and I agree that it is correct as stated.

* I have agree to provide all required documentation requested by the program. If not, I understand that I could be asked to surrender my seat in the Paramedic Program.

* I agree to the total tuition due and payment plan for money owed to Central Jackson County Fire Protection District. I understand that failure to pay any installment when due may result in my removal from the program. I understand and agree that after the first day, neither my voluntary withdrawal nor my involuntary removal from the program will release me of my financial obligation to Central Jackson County Fire Protection District.
Release Authorization:

Clear
SmallMediumLarge1x2x3x4x
Additional Comments
Non-refundable Application Fee
prevnext( X )
Employer responsible for non-refundable application fee
$ Free Quantity

EMT/Paramedic non-refundable application fee
EMT-This holds your spot in class.. Paramedic--This covers the cost of the Entrance Exam.

$50.00 Quantity

Total

$0.00
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EMT/Paramedic Student Registration Form