To enroll in a course, please complete this form and press the Submit Form button at the end.
| First Name | |
| Last Name | |
| Middle Initial | |
| Street Address | |
| City | |
| State/Province | |
| Zip/Postal Code | |
| Cell Phone | |
| Home Phone | |
Which course would you like to enroll in?
EMT-Basic Original Course
EMT Refresher/Challenge Refresher
Pilot EMT Refresher Core Content Course
Do you belong to a recognized NYS EMS response agency?
Yes No [if no, please note that tuition charges will apply]
If yes, enter the name of your department or agency in the space below.
Are you now, or have you ever been certified as a NYS EMT or CFR?
Yes No
If yes, please enter your NYS EMT or CFR #
When will (or did) your NYS certification expire?
-- mm/dd/yy
NOTE: You are not registered in a course until you receive email or phone confirmation.
Trouble with this form?
Don't freak out! Click the envelope to email us your complaint:
