ECRN REGISTRATION FORM

Endeavor Health

Highland Park Hospital EMS System

Emergency Communications Registered Nurse (ECRN) Course

ECRN Registration Form

FORM DUE DATE: May 1, 2026

Didactic: EMS HPH Classroom

Time: 9:00am - 2:30 pm

Class Dates:

May 18, Monday

May 22, Friday

May 27, Wednesday

May 29, Friday

June 1, Monday

June 5, Friday

Final Examination

June 8, Monday - Final Exam

Ride Time with Provider Agency

June 2, 2026

June 3, 2026

June 4, 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.
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 -November 11, 2025
Ride Time Date Preference - November 12, 2024
Ride Time Date Preference - November 13, 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

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BLS/CPR Card

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ACLS Card

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PALS

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Signature

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Date

MonthDayYear
Date
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ECRN Registration Form

Required Licenses/Certification

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