Paramedic Refresher Initial Registration Form

Paramedic Refresher Initial Registration Form

The Paramedic Refresher course is intended for and structured to meet the needs for those already certified as a Paramedic needing to re-certify. Students needing hours to be eligible to take either NREMT (National Registry of Emergency Medical Technicians) exams will need to register for one our Prep Week Courses.

** IMPORTANT **
Fill out this form to show your interest in our Paramedic Refresher. Once you submit it, someone from our team will reach out to you with the next steps to finish the registration process.

Depending on your email inbox settings, this important message might end up in your junk mail folder. If you haven’t heard back from us within 2 business days after sending your application, be sure to check your junk mail folder. If you still don’t see a response, feel free to reach out to us.

Payment Methods: We will send you an electronic invoice that you can easily access whenever you want.

Course Cost: $500

Student Information

Name *

First

Last

Email *

Email

Confirm Email

PSID Number *

Date of Birth *

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Age *

Gender *

• Male
• Female

Cell *

Shirt Size *SmallMediumLargeXL2XL3XL

Are you interested in on-site housing? *

• Yes
• No

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

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Relationship to Student *

Address *

Address Line 1

City

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Zip Code

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County

Address

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Address Line 2

City

State / Province / Region

Postal Code

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For International Students

• International Address

Are you being sent by your employer? *

• Yes
• No

Please enter company name *

Paramedic Refresher Course dates *

• TBD

Reason for taking this course *

Where did you hear about us?

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

If Other, Please tell us more.

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