Paramedic Refresher Registration Form

Paramedic Refresher Registration Form

This course is intended for and structured to meet the needs for those already certified as a Paramedic needing to recertify. Students needing hours to be eligible to take either NREMT exams will need to register for one our Prep Week Courses.

Upon receipt of your registration form, Pelham Training will reach out to you via e-mail to the address you have listed on your registration form.

Depending on how you have your e-mail inbox configured, this important email may go to your junk mail folder. If you have not received a response within 2 business days of transmitting your application to us, please check your junk mail folder. If you still have not received a response, please contact us.

Methods of Payment: The balance is due on or prior to the first day of class. We accept cash, check or card.

Student Information

Name *

First

Last

PSID Number (if Indiana Resident) *

If you are not an Indiana Resident, please put N/A in this field.

Address *

Address Line 1

City

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

Zip Code

County *

County

Cell *

Email *

Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Age *

Gender *

• Male
• Female

Are you interested in on-site housing? *

• Yes
• No

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

Paramedic Refresher Course dates *

• February 20 - 24
• September 25 - 29

Reason for taking this course *

Emergency Contact *

First

Last

Emergency Contact

Emergency Contact Phone Number *

Relationship to Student *

Where did you hear about us?

• Web Search
• Facebook
• Twitter
• In-Person Event
• Referral from Friend/Colleague
• Other

If Other, Please tell us more.

Submit