ECRN REGISTRATION FORM

Endeavor Health

Highland Park Hospital EMS System

Emergency Communications Registered Nurse (ECRN) Course

ECRN Registration Form

FORM DUE DATE: May 14th 2025

Didactic: EMS HPH Classroom

Time: 9:00am - 2:00 pm

Class Dates:

Friday 5/23

Wednesday 5/28

Friday 5/30

Monday 6/2

Friday 6/6

Monday 6/9

Final Examination

June 13, 2025 Friday

Ride Time with Provider Agency

June 3, 2025

June 4, 2025

June 5, 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 -June 3, 2024
Ride Time Date Preference - June 4, 2024
Ride Time Date Preference - June 5, 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.