Course Registration Form

K.F.P.D. EMR Registration Form

Fill out the form carefully for registration
First class date will be August 13th and continue every Tuesday and Thursday from 6pm to 10pm. Final tentative class date will be October 1st.

Cost of the class is $300. Due by the first class date. This class fee will be waived if you sign a contract, stating you will provide services to Kansas Fire Department for a minimum of 2 years upon successfull completion of the class and a Valid IL IDPH EMR License. No felony convictions. Must have Valid DL and be age 16 or older by completion of the class.

The location of the class is TBD, however it will be in Kansas, IL
Date

MonthDayYear
Date
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Any Felony Convictions?

YesNo
Do you plan on affiliating with Kansas Fire Protection District upon Licensure?

YesNo
Valid DL License?

YesNo
Additional Comments
Kansas Fire Protection District

400 W. Buena Vista St.

Kansas, Il 61933

Email: Kansasambulance@gmail.com

925-250-2445
Should be Empty:

K.F.P.D. EMR Registration Form