EMS Training Inc. - Registration Form

Course Application.

Name:
Street Address:
City, State, ZIP:
Email Address:
Phone:
Pager Number:
Course:
Course Name:
Location:
Starting Date:
Current Certifications:
CPR	CPR Instructor
First Responder	First Responder Instructor
Previous EMT	Other:
Reason for wanting to take the course:

NOTE: The Office of Emergency Medical Services (OEMS) requires 100% attendance of all students and a passing grade of at least 70% in order to successfully complete the course and be eligible to take the state certifying EMT written and practical exam.