2026 EMT Basic Registration Form

2026 EMT Basic Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Format: (000) 000-0000.
Shirt Size
Valid Driver's License
Do you have a high school diploma or GED?
Do you have a valid CPR card or will you need one? (We will be offering the CPR card with your tuition if it is needed.)
Do you currently have the required immunizations or will you be able to obtain them before class begins? (Required: Hepatitis B & TB shot or proof of negative test. Suggested: TDAP, MMR, Flu Vaccine)
Additional Comments
Should be Empty: