EMT Basic

EMT Basic Registration Form

Please fill in the form below.
If you have any questions, please do not hestiate to contact us at 1-574-269-1975 ext 710
Today's Date: *

Month Day Year
Date
Full Name *

First Name Last Name
Address *

Street Address

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City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Driver's License *
Date of Birth *

Month Day Year
Date
Indiana PSID *
If you do not have one, please indicate here*
Current EMS Affiliation?
List 2 Personal References with contact information: *
Do you have a high school diploma or GED? *
Upload GED/High School Diploma

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Please tell us why you want to take the EMT Class? *
What is your shirt size for unisex polo? *
This will be used to order polo shirts for Clinical Internships. You will also need to have black closed toe shoes and tactical EMS pants for clinical rotations at the cost of the student.
I acknowledge that I have access to a laptop or tablet that would be accessible for each class period throughout the program. *
I acknowledge that I will be required to have a three series Hepatitis B vaccine, TB Shot, background check and urine drug screen on file before I can start clinical rotations. *
The Hepatitis B Vaccines and TB shot are at the cost of the student. The background check will involve paperwork filed in class and a $7.00 cash payment will be due in class. The drug screens will be provided to the students at no cost.
I understand that a $100 non-refundable application fee is due in full for a position to be saved in the class for myself. I understand that upon completion of my background check, the class fees of $350 for affiliated fire department personnel and $500 for general public must be paid in full by the first day of class. *
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EMT Basic Registration Form