Student Enrollment Form MFR

Student Information Collection Form

Medical First Responder Class 2025
General Information
Student Name*

First NameMiddle NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
SelfEmployer / Department
If Employer / Department Paid, Please provide contact information:
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, above named student, authorize and give consent for Perry Area Fire Rescue to obtain information regarding myself. This includes the following:

* Criminal Background Check - via ICHAT (Internet Criminal History Access Tool)

I the undersigned, authorize this information to be obtained in connection with my application for enrollment in the offered EMS program. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization’s guidelines.

By signing this document, I am providing Perry Area Fire Rescue my consent for a background check in accordance with the requirements of my selected EMS education program.
Signature

Clear
File Upload: Please upload a copy of your Driver License and required vaccination records. You will be required to provide proof of vaccination, for the following: Tetanus, Diphtheria, MMR, Hepatitis B and a negative TB skin test prior to starting class.

Cancelof
If you have any difficulty with the application or submitting documentation, please contact Lois Szostak at LSzostak@pafr.org
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Student Information Collection Form

General Information