EMS Education Course Registration Form

EMS Education Course Registration Form

Registration Form

Fill out the form carefully for registration
Personal Information
Student Name*

First NameMiddle NameLast Name
Birth Date*

YearMonthDay
Gender
I am UNDER 18 years old:*

Yes (< 18)No
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address*
example@example.com
Mobile Number*
Phone Number*
Select the course you are registering for:*
Polo Shirt Size
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship*
How did you hear about us?*

Students applying to this course must be able to present:
- Valid state or US government-issued picture ID.
- High school diploma or GED.
1. All students are required to provide proof of immunization including documentation of either receiving the required vaccine or a titer showing immunological response. The minimum required immunizations include Hepatitis B, TDAP, Tuberculosis, MMR, Influenza, and Varicella. Some clinical sites may require proof of COVID-19 vaccination.

2. All prospective students must pass a criminal background check and urine drug screen. Students will not be enrolled if they fail to meet the requirements of the NREMT or of Texas DSHS.
Signature

Clear

My Products*

EMR/EMT Basic DepositDeposit for your course registration

$100.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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