17-Day EMT Student Enrollment Packet

Name (Required)

First

Middle

Last

Preferred Name

Date of Birth (Required)

Cell Phone (Required)

Email (Required)

Confirm Email

Mailing Address (Required)

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (Required)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Check if you're using an International adress

International Student

Course Date (Required)

October 1st – 17th, 2026
November 5th – 21st, 2026
December 3rd – 19th, 2026
Request a different class date

Have you graduated from high school or earned a GED or equivalent?

If documentation is required, it may be submitted below or provided as directed by Pelham staff.

Emergency Contact (Required)

First

Last

Relationship to Student (Required)

Emergency Contact Phone (Required)

Will you be staying in Pelham student housing? (Required)

Yes
No
I am still deciding

Expected Arrival Date (Required)

Expected Departure Date (Required)

Do you have any housing-related questions or needs we should discuss before arrival?

Will you have transportation available during the course? (Required)

Yes
No
I need to discuss transportation options with Pelham

Shirt Size (Required)

How will your training be funded? (Required)

Self-pay
Employer / Agency
VA education benefits
Military
Other

If using VA education benefits: Pelham staff will contact you regarding the documentation required for VA processing.

If employer or agency funded:

Organization / Agency Name (Required)

Billing Contact Name (Required)

First

Last

Billing Contact Email (Required)

Billing Contact Phone (Required)

Required Documents

Please provide any documents required for your enrollment.

Possible documents may include:

□ Identification

□ High school diploma or GED documentation

□ Employer or agency sponsorship paperwork

□ Military or VA-related documentation, if applicable

□ Other required program documentation

Document Upload

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Accessibility & Learning Accommodations

Pelham wants students to have an appropriate opportunity to participate in their education.

Would you like to speak privately with a Pelham staff regarding a disability, learning accommodation, or other accessibility need?

A Pelham staff member will contact you privately. You do not need to provide medical details on this form.

Important Course Information

Please review the following statements. (Required)

I understand that this is an accelerated 17-day EMT program, and that attendance and participation requirements are important to successful completion of the course.

Checkboxes (Required)

I understand that additional enrollment documents or required records may need to be submitted before the course begins.

Checkboxes (Required)

I understand that submission of this enrollment packet does not replace any separate payment, funding, or documentation requirements communicated by Pelham.

Is there anything else Pelham should know before your class begins?

Student Certification

Checkboxes (Required)

I certify that the information provided in this enrollment packet is accurate to the best of my knowledge.

Signature (Required)

Clear Signature

Name (Required)

First

Last

Date (Required)