36-hour Registration Form

EMT Refresher Registration Form

** IMPORTANT **
Upon submitting your registration form you will receive an email with further information regarding arrival and payment.

Name *

First

Last Name *

Last

Address *

City *

State *

Zip Code *

County *

Cell Phone *

Email *

Age *

Date of Birth *

Gender

Male

Female

Are you interested in on-site housing?

Yes

Addition cost. $70/night. kitchen - showers - laundry - rec room

EMT REFRESHER DATES *

June 24 - 26, 2021

Reason for needing the course.

EMT Recertification

Cognitive Remediation

OtherOther

Additional Information, Questions or Concerns