EMERGENCY MEDICAL SERVICES TRAINING COURSE              

STUDENT REGISTRATION / PROFILE                   

NAME:                                                                                    DOB:                                      

 ADDRESS:                                                                              TOWN:                                  

 ZIP CODE:                               S.S.#:                                                    CERT     RE-CERT

 PHONE: (D):                                       (E):                                              EMT       EMT-IV     MRT

 CERTIFICATION NO.:                                  EXPIRATION DATE:                              

CPR EXPIRATION DATE:                                       

 SERVICE AFFILIATION:                                                                   

 OCCUPATION:                                                                               

 PHYSICAL HANDICAPS/LIMITATIONS:                                                                                

 I am aware of the scope of this Emergency Medical Services training program and shall make no claims against the sponsoring agency, the primary instructor or, any of his agents/employees, for any injuries that I may sustain as a result of participating in this training program.   As well, all information contained herein is true and accurate.

 APPLICANT’S SIGNATURE:                                                              DATE:                        

 This certifies that the above named applicant is a member in good standing of the above listed sponsoring Emergency Medical Services organization.

 CHIEF OF SERVICE SIGNATURE:__________________________DATE:_____________

 PAYMENT OR PURCHASE ORDER MUST ACCOMPANY EACH APPLICATION OR GROUPS OF APPLICATIONS.

MAKE CHECKS PAYABLE TO: “ERM” and SEND TO:  

______ (EMT Refresher $175.00)

______ (MRT Refresher $150.00)

PO #:                                       DATE:                                    

DC:                  PC:                  DATE:                          NO: