EMT Registration

First Name:
Last Name:
Street Address:
Apartment Number:
City:
State:
Zip:
Phone Number:
E-Mail:
Courses:
Payment Ammount:
	If you are enrolling in an Advanced program you must Complete the Advanced EMT agreement. Download Application here. If you are enrolling in a Basic program you must Complete the Basic EMT agreement. Download Application here. 25% Deposit required to register EMT-B Courses get a $50 discount for payment in full EMT-A Courses get a $200 discount for payment in full Paramedic Courses get a $1,000 discount for payment in full All other courses require full payment
EMT Schedule:
Course Date:	(MM/DD/YY)
Name on Card:
Type of Card:
Card Number:
CSC:
Expiration Date:	(MM/YY)
	I understand that my credit card will be charged the amount above upon receipt of registration form.
Please Initial: