• CONTOMS EMT-T Basic Course #143 Application

    June 12 - 16, 2023: Westchester, NY
  • 1. Contact Information 

    Please provide your full legal name and home address as this information is required for us to capture for certain accrediting boards (CAPCE) and certificates.

  • 2. Work Experience

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  • 3. License Information

  • The following information must be provided if you would like to receive EMT/Paramedic credits for completion of this course. If you are not seeking EMT/Paramedic credits, please skip this section.

  • 4. Student Contact Information Form: (for onsite training purposes)

  • 5. General Release

    The  United  States  and/or  Chesapeake  Health  Education  Program,  Inc or their  lawful designees  have requested me to grant, release and discharge to it, certain rights (herein after more fully set forth) arising from my participation in a particular production (be it a motion picture film, television recording, or digital imaging) to be made or produced for the United States Government.

    This grant, release and discharge of said rights to the United States and or Chesapeake Health Education Program, Inc or their lawful assignees is made and without expectation of recompense of any kind, in full cognizance of the risks inherent in the operations, techniques employed in the production, including but not limited to, the focusing of lights upon me; and in contemplation of the reliance by the United States and/or Chesapeake Health Education Program, Inc or their lawful assignees upon the rights herein granted and released.

    I hereby grant and release the United States and/or Chesapeake Health Education Program, Inc or their lawful assignees the following rights:

    Use of my name, photograph, likeness, acts, poses, plays, and appearances made in connection with the said production in any manner; to record, reproduce, amplify, simulate, filter or otherwise distort my voice and all instrumental, musical, and other sound effects produced by me; and to reproduce, duplicate, publish, exhibit, and use or transmit the same or any parts thereof, by any means, in any manner and for any purpose whatsoever and to use the same perpetually.
    The right to "double" or "dub" my voice, act, poses and appearances, all instrumental, musical, and other sound effects produced by me to such an extent as may be desired by the United States and/or Chesapeake Health Education Program, Inc or their lawful assignees.
    The release and discharge of the United States and/or Chesapeake Health Education Program, Inc or their lawful assignees from any cause of action whatsoever nature arising from my participation in the production.
    This voluntary grant and release will not be made the basis of future claim of any kind against the United States and/or Chesapeake Health Education Program, Inc, its employees, assignees, contractors, or employees or agents of the same.

    This grant, release and discharge of said rights to the United States and or Chesapeake Health Education Program, Inc, and its officers, agents, servants and employees when acting in their official capacities, and to persons, firms, or corporations contracting with the United States and or Chesapeake Health Education Program, Inc and their  heirs, executors, administrator,s successors  or assigns; and any  other persons lawfully reproducing , distributing, exhibiting or otherwise using the said production or any portion thereof.

    In the event that this General Release is signed in connection with any other release, that language in each release that provides the greatest rights to the United States and/or Chesapeake Health Education Program, Inc or their lawful assignees shall control.

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  • Please contact Carly Spiewak cspiewak@chepinc.org or 484-710-1002 should you have any questions about this application.

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