Paramedic Program Registration Form

Name *

First

Last

PSID Number *

If you have not yet applied for a PSID, please put N/A in this field.

Address *

Address Line 1

City

State

Zip Code

County *

County

Cell *

Email *

Date of Birth *//

Age *

Shirt Size *

Gender *

Male
Female

Are you interested in on-site housing? *

Yes
No

Additional cost: $70/night (see Student Housing for details)

GI Bill Benefits for Veterans *

Yes
No

Paramedic Program Course dates *

January 3 - April 22, 2023
March 20 - July 15, 2023
June 12 - October 7, 2023
August 28 - December 16, 2023

Why do you want to become a Paramedic? *

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

Current or previous background in Military or as a Firefighter? *

Yes
No

Please provide details *

Are you being sent by your employer? *

Yes
No

Please enter company name *

Additional information, Questions or Concerns

Emergency Contact *

First

Last

Emergency Contact

Emergency Contact Phone Number *

Relationship to student *

Where did you hear about us?

If Other, Please tell us more.

Paramedic Program Registration Form

Paramedic Program Registration

Course cost: $13,500 (Excludes Housing and Car Rental)

Student Information