EMR INTEREST LIST
This form is designed to establish a list of individuals who are interested in receiving information on the next Emergency Medical Responder (EMR) course. We host these courses based on interest to ensure we have enough for each course. Once we have enough interest, we will email everyone on the list an update to when we plan to start the next course. The course is approximately 10 weeks long and hosted online through JB Learning. There are typically 3 classroom days that include taking the final exam, skills practice, and the National Registry Skills Exam.
Name
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Are you associated with any organization?
Texas Search and Rescue
Fire Department
Law Enforcement
Texas Military Forces
Other
Please tell us a little more about yourself. For example, what department/organization you are with? Why you would like to take the course? Etc.
Thank you
Thank you again for your interest in the EMR course. When you click submit, a confirmation email will be sent to you shortly. If you do not receive this email within 24 hours (check your junk mail), please submit again. If you have any further issues, please contact Eric.Steffel@NWCommunityHealth.org.
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