Course Registration Form

Course Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number
Courses
Additional Comments
My Products*
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Emergency Medical ResponderEnter description
$900.00 Quantity
Item subtotal:$0.00



Emergency Medical Technician Basic
$2,000.00 Quantity



Firefighter Academy
$3,000.00 Quantity



Reserve My Spot- EMRThis will hold your place if you cannot pay in full. We will be in contact to set up a payment plan.
$500.00 Quantity



Reserve My Spot EMTThis will hold your place if you cannot pay in full. We will be in contact to set up a payment plan.
$500.00 Quantity



Reserve My Spot- Fire AcademyThis will hold your place if you cannot pay in full. We will be in contact to set up a payment plan.
$500.00 Quantity



Subtotal

$0.00

Tax

$0.00

Total

$0.00
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