Paramedic Program Registration Form

** IMPORTANT **
Upon submitting your registration form you will receive an email with steps to complete the registration process.

All students attending the Paramedic Program must apply for a PSID # from the Indiana Department of Homeland Security. You MUST have your PSID # prior to the beginning of class. Students attending the Paramedic Program from places outside Indiana are still required to have a PSID # prior to the beginning of class. There are no exceptions.

Complete information on how to apply for your PSID # will be included in your Welcome Packet that you will receive once the registration process is complete.

Methods of Payment: A down payment to hold your seat is required, payable by phone. The remaining balance is due on or prior to the first day of class. Payment schedules are available upon request.

Student Information (All Fields Required)

Name *

First

Last Name *

Last

PSID Number (Indiana residents only) *

Address *

City *

State *

Zip Code *

County *

Cell Phone *

Email *

Age *

Date of Birth *

Shirt Size *

Gender

Male

Female

Are you interested in on-site housing?

Yes

Additional cost. Payment plan available.

GI Bill Benefits for Veterans? *

Yes

PARAMEDIC PROGRAM *

March 22 - July 17, 2021

June 7 - Oct. 2, 2021

Aug. 23 - Dec. 18, 2021

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?

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

Current or previous background in Military or as a Firefighter?

Are you being sent by your employer? If yes, please place the company name.

Additional Information, Questions or Concerns