ECRN REGISTRATION FORM

Endeavor Health

Highland Park Hospital EMS System

Emergency Communications Registered Nurse (ECRN) Course

ECRN Registration Form

FORM DUE DATE: April 14th 2025

Didactic: EMS HPH Classroom

Time: 9:00am - 2:00 pm

Class Dates:

Friday 5/9

Monday 5/12

Friday 5/16

Monday 5/19

Friday 5/23

Wednesday 5/28

Final Examination

May 30, 2025 Friday

Ride Time with Provider Agency

May 20, 2025

May 21, 2025

May 22, 2025
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.
Personal Email
example@example.com
Current Hospital Affiliation

EvanstonGlenbrookHighland ParkSkokieResourceOther (Condell/Lake Forest)
Length of Employment in Current Emergency Department
Length of Employment as an Emergency Nurse
EMT or Paramedic Experience

YesNo
If Yes, Please Provide Expiration Date of EMT/Paramedic License
Required Licenses/Certification
Ride Time Date Preference - September 24, 2024
Ride Time Date Preference - September 25, 2024
Ride Time Date Preference - September 26, 2024
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
BLS/CPR Card

Cancelof
ACLS Card

Cancelof
PALS

Cancelof
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

ECRN Registration Form

Required Licenses/Certification

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