ECRN REGISTRATION FORM

Endeavor Health

Highland Park Hospital EMS System

Emergency Communications Registered Nurse (ECRN) Course

ECRN Registration Form

FORM DUE DATE: October 1, 2026

Didactic: EMS HPH Classroom

Time: 9:00am - 2:30 pm

Class Dates:

Start Date Friday, October 16, 2026

Monday, October 19, 2026

Friday, October 23, 2026

Monday, October 26, 2026

Friday, October 30, 2026

Tuesday, November 3, 2026

Final Examination Monday, November 9, 2026

Ride Time with Provider Agency

October 27, 2026

October 28, 2026

October 29, 2026
Applicant Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Personal Email
example@example.com
Ride Time Date Preference - October 27, 2026
Ride Time Date Preference - October 28, 2026
Ride Time Date Preference - October 29, 2026
Current Hospital Affiliation
Length of Employment in Current Emergency Department
Length of Employment as an Emergency Nurse
EMT or Paramedic Experience
If Yes, Please Provide Expiration Date of EMT/Paramedic License
Required Licenses/Certification
Basic Arrhythmia Course (Date of course completion)

MonthDayYear
Date
Social Security Number ( Required for initial ECRN licensing )
Please Upload PDF's or Scanned Images of required documents.

Photo's and/or screenshots of requested items with various backgrounds present are not permissible.
RN License

Cancelof
Driver's License

Cancelof
BLS/CPR Card

Cancelof
ACLS Card

Cancelof
PALS

Cancelof
Signature
Date

MonthDayYear
Date
Should be Empty:

ECRN Registration Form

Required Licenses/Certification

Please Upload PDF's or Scanned Images of required documents.