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 EMAIL! YOU MUST ALSO DOWNLOAD AND COMPLETE AN OFFICIAL NYS APPLICATION FORM. YOU MAY BRING THIS FORM WITH YOU ON THE FIRST DAY OF CLASS .

Personal Information

Please tell us who you are, and how to contact you.

Last Name

First Name

Middle Initial

NYS EMT/CFR Number (if any)

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.

Mailing Address

Enter your US Postal Service mailing address (street address, or PO box).

City

State

Zip Code

Enter your US Postal Service Zip Code (Zip +4, if you know it).

Home Phone (with Area Code)

Enter the phone full number (with area code) that you use to receive calls at home. Please use the format xxx-xxx-xxxx.

Mobile Phone (with Area Code)

Please enter your mobile (cellular) phone number, if different from your home phone number, using the format: xxx-xxx-xxxx.

Email Address

Enter an email address to which we should send an acknowledgement, and at which you can be reached with important information.

Course for Which You are Registering

Please describe the course (and section, if there are multiple ones available) that you wish to attend. Refer to upcoming course information for details on available courses.

Level of Certification/Recertification

Please select the NYS EMS provider certification level of the course you are registering for.

Course Type

Please select the type of course you wish to register for from among the available options.

Semester

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).

Schedule (Days of the Week)

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).

Schedule (Time of the Day)

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

Please specify your PRIMARY EMS agency affiliation. Please note that your affiliation will determine your eligibility for New York State funding of your course tuition (refer to our Tuition, Fee, and Required Textbook polcy for more information). If you do not see your agency on this list, select "Other Agency – Specify Below" and type your agency name in the following field. PLEASE NOTE THAT YOU WILL BE REQUIRED TO PROVE YOUR EMS AGENCY AFFILIATION.

EMS Agency Name

Select Your Primary EMS Agency Affiliation (through which you are applying for this course).

Other EMS Agency (Specify)

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Emergency Medical Services Education Course Pre-Registration Form

Neal Haight ACTING DIRECTOR

Neal Haight
ACTING DIRECTOR