Student Information Sheet
We need more information from each student to make things move more smoothly on the first day of class and continue moving forward. Help us by filling in your personal information in the form below.
Personal Information
Name
*
Mr.
Mrs.
Miss.
Ms.
Prefix
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
01/01/1901
Gender
Male
Female
Mobile Number
*
999-999-9999
Format: (000) 000-0000.
Email
*
example@example.com
Driver's License Number
*
DLN # 0123-45-6789
Format: 0000-00-0000.
Public Safety Identification Number
PSID # 9999-9999
Format: 0000-0000.
Federal Emergency Management Agency Student Identification Number
FEMA SID #0123456789
Format: 0000000000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information
Affiliation: (Fire Department, Medical Service, Company, Workplace, Ect)
*
Who Will be Providing Tuition Payment?
*
Self-Pay (Student Pays in Full)
Self-Pay (Requesting Payment Plan Options- Please Contact the Lead Instructors at medtrainingandconsutling@gmail.com)
Affiliated Business (Invoice Required)
Affiliated Business (No Invoice Required, Payment Being Provided in Full)
Other
Any CPR Experience?
*
Never Taken a CPR Course Before
Previously CPR Certified by AHA (American Heart Association), Currently Expired
Previously CPR Certified by a Different Trained Agency (I.e. American Red Cross), Currently Expired
Currently BLS Provider CPR Certified by AHA (American Heart Association)
Currently BLS Provider CPR Certified by a Different Trained Agency (i.e. American Red Cross)
Other
Any EMR Experience?
Previously Certified EMR, Currently Expired
Previously Attended EMR Course, Did Not Complete/Pass
No EMR Experience, This is My First Course!
Prefer Not to Answer
Other
What Style of Learning Do You Do Best With, in a Classroom Environment?
Visual: Learning Through Seeing (Powerpoints, Picture Aids, Charts/Graphs, Outlines)
Auditory: Learning Through Listening (Read-out loud/alongs, Lectures, Discussions)
Reading/Writing: Learning Through Reading and Writing (Books/Texts, Note-Taking)
Kinesthetic: Learning Through Doing and Experiencing (Incorporate Body Movement, Hands-On)
Emergency Contact
Name
*
Mr.
Mrs.
Miss.
Ms.
Prefix
First Name
Last Name
Relationship to Student
*
Please Select
Husband
Wife
Significant Other
Son
Daughter
Father
Mother
Brother
Sister
Aunt
Uncle
Grandfather
Grandmother
Niece/Nephew
Fiance/Fiancee
Friend
Others
Mobile Number
*
999-999-9999
Format: (000) 000-0000.
Any Questions or Concerns?
Submit
Should be Empty: