EMR Class Registration

EMR Registration Form

Please fill in the form below.
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I am registering for ...*

Miami County Course located at Dukes Memorial 275 W 12th St Peru, IN - Mondays and Wednesdays 6pm-10pm Primary Instructor: Chris Wagner 07/07 through 09/01Kosciusko County Course located Lutheran Kosciusko Hospital 2101 E Dubois Drive Warsaw, IN - Mondays and Wednesdays 6pm-10pm Primary Instructor: Tony Hartman - 07/02 through 08/30
Current EMS/Fire Affiliation?
List 2 Personal References with contact information:*
Do you have a high school diploma or GED?
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Please tell us why you want to take the EMR Class?*
By typing my initials in below, I understand that in order to take this course, I will be required to receive Hep B vaccination series, TB test, submit to a drug screen, and background check. I understand that these will all be completed at my own cost not associated with the course fees.*
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By typing my initials in below, I understand that I will have access to an electronic device available to me for each and every course to be able to complete required assignments.*
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I understand that a $150 non-refundable class payment fee with be due upon submission of this application. I understand that until my payment is received in full my spot is not guaranteed. Cash payments can be made in person in the administrative offices located at 445 Anchorage Road or by mailing a check made out to Kosciusko Ambulance LLC to the above address. Receipt of payment confirms your seat in class and a confirmation email of receipt will be sent to email listed above. *
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***Update: 12/23/2021 - I understand that the class roster is now full; however, if a spot will become available I will be contacted.*

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EMR Registration Form