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EMT Registration Form
EMT Registration Form
If you see this don't fill out this input box.
Semester
*
Please Select
Spring 2024
Select semester you are registering for
First Name
*
Middle Initial
Last Name
*
Other Name(s) Used
Address1
*
Address1
City
*
City
State
*
State
Zip
*
Zip
Phone
*
E-mail Address
*
Date of Birth
*
Gender
Enter your gender
Citizenship
*
Please Select
U.S.
Permanent U.S. Resident
Non-resident alien
Other
Select country of residence
EMS Courses
*
Please Select
Spring 2024 EMT Original (evening) - Essex County Public Safety Building
-Spring 2024 EMT Refresher (evening) - Essex County Public Safety Building
Spring 2024 EMT Original (daytime) - Essex County Public Safety Building
-Spring 2024 EMT Refresher (evening) - Essex County Public Safety Building
Spring 2024 CFR Original (evening) - Essex County Public Safety Building
Spring 2024 AEMT Original - NCCC Saranac Lake Campus
Please select course
RegistrationStatus
Non-Credit, I am a volunteer member or employee of NYS EMS Agency
Non-Credit, I am not a volunteer member of employee of a NYS EMS Agency
Credit College Student (additional tuition costs apply)
Select Registration Status
Payment Method
My agency or employer we paying for the course
I would like to make payment arrangements
If online payment or check-by-mail is chosen, you will receive an e-mail with instructions on how to proceed after submitting request.
EmployerAgencyPaying
Please provide address if Employer or Agency will be paying for the course.
Verification
I am the individual requesting to be registered for the courses listed above.
I understand, that by signing this registration form, I am formally registered for the above indicated semester and have incurred a financial obligation to pay for these courses unless I formally drop the courses in writing prior to the start of the semester.
Signature
*
Enter your full name - Parent/guardian signature if registrant is under 18 years of age.
Date
*
Enter today's Date
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Last Updated 11/20/23
Last Updated