17-Day EMT Program Initial Registration Form

** IMPORTANT **
Fill out this form to show your interest in our 17-day EMT Program. Once you submit it, someone from our team will reach out to you with the next steps to finish the registration process.

Depending on your email inbox settings, this important message might end up in your junk mail folder. If you haven’t heard back from us within 2 business days after sending your application, be sure to check your junk mail folder. If you still don’t see a response, feel free to reach out to us.

Students must be at least 18 years old and hold a High School Diploma or GED to get certified. We can allow younger students if the admin approves it, but those under 18 can’t get certified until they turn 18.

Payment Methods: We will send you an electronic invoice that you can easily access whenever you want.

Course Cost: $3,800

Cost Includes:

• Tuition
• Handouts
• Clinical Assignments
• Logo Shirt – x2
• Photo ID Badge
• Stethoscope
• Class Certification (provided by AHA at no additional cost to you)

Although staying on site is not a requirement, it is encouraged as it can benefit the students overall learning experience by enabling them to study and support each other throughout the course.

View Student Housing for more details.

Student Information

Name *

First

Last

Email *

Email

Confirm Email

Date of Birth *

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Age *

Gender *

• Male
• Female

Cell *

Shirt Size *SmallMediumLargeXL2XL3XL

Are you interested in on-site housing? *

• Yes
• No

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Relationship to student *

Address *

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

County *

County

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

For International Students

• International Address

GI Bill Benefits for Veterans *

• Yes
• No

Do you have a Letter of Eligibility? *

• Yes
• No

Social Security Number *

17-Day EMT Academy Course dates *

• October 1st – 17th, 2026
• November 5th – 21st, 2026
• December 3rd – 19th, 2026

Do you have any learning disabilities, allergies or medical information we need to be made aware of? *

• Yes
• No

Please provide details *

Please be specific so instructors are aware for hands-on scenario situations

Are you being sent by your employer? *

• Yes
• No

Please enter company name *

Will you be driving your own vehicle? *

• Yes
• No

If you are not, we can help arrange for a rental, or for you to carpool with another student, please contact us if you need any assistance

Additional information, Questions or Concerns

Where did you hear about us?

• Web Search
• Facebook
• X
• Instagram
• TikTok
• In-Person Event
• Referral from Friend/Colleague
• Other

If, Other, Please tell us more.

Submit