Emergency Medical Services Education Course Pre-Registration Form

PLEASE REFER TO SPECIFIC COURSE(S) FROM CURRENT COURSE INFORMATION. YOU MAY ONLY SUBMIT FOR ONE COURSE AT A TIME!  A CONFIRMATION WILL BE SENT TO YOUR EMAIL TO CONFIRM YOUR PRE-REGISTRATION IN THE COURSE, BUT YOU ARE NOT "OFFICIALLY" REGISTERED IN A COURSE UNTIL YOU HAVE RECEIVED WRITTEN CONFIRMATION OF YOUR PLACEMENT BY US MAIL! YOU MUST ALSO DOWNLOAD AND COMPLETE AN OFFICIAL NYS APPICATION FORM . YOU MAY BRING THIS FORM WITH YOU ON THE FIRST DAY OF CLASS .

Personal Information
Please enter your New York State EMT of CFR number, if you have one (even if your certification is currently expired). Leave blank if you have no such number.
Enter your US Postal Service mailing address (street address, or PO box).
Enter your US Postal Service Zip Code (Zip +4, if you know it).
Enter the phone full number (with area code) that you use to receive calls at home. Please use the format xxx-xxx-xxxx.
Please enter your mobile (cellular) phone number, if different from your home phone number, using the format: xxx-xxx-xxxx.
Course for Which You are Registering
Please select the NYS EMS provider certification level of the course you are registering for.
Please select the type of course you wish to register for from among the available options.
Select the semester (spring, summer, or fall) during which you wish to attend the desired course. If the course you desire is not offered during the specified semester, you will be registered for it during the next semester in which it is available).
Select the schedule (days of the week) on which you wish to take the desired course (NOTE: if your desired schedule is not available during the semester you specify, you will be registered for the one that most closely resembles your preferences).
Select the schedule (time of the day) on which you wish to take the desired course (NOTE: if your desired schedule is not available during the semester you specify, you will be registered for the one that most closely resembles your preferences).
Your EMS Agency Affiliation
Select Your Primary EMS Agency Affiliation (through which you are applying for this course).
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