On-Line Course Registration

To enroll in a course, please complete this form and press the Submit Form button at the end.

Please provide your contact information:

First Name

Last Name

Middle Initial

Street Address

City

State/Province

Zip/Postal Code

Cell Phone

Home Phone

E-mail
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, what level of certification do you (or did you) hold?
CFR
EMT
Advanced EMT

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: