EMT Class Enrollment Form

EMT CLASS ENROLLMENT FORM

This Enrollment Form registers the Applicant for the Emergency Medical Technician (EMT) Initial Certification Course offered by the Program. Completion of enrollment and acceptance are contingent on verification of prerequisites, successful background and health screenings where required, and payment of required fees. Applicant must read and acknowledge the program policies and consents below.

Student Information

Date of birth:   Student ID (if assigned):

Emergency & Medical Information

Physical limitations that may affect participation: Yes    If yes, describe:

Enrollment Details & Fees

Program selection:    Session ID:

Class start date:    Expected class schedule / hours:

Balance due date:

Full payment at registration    Installment plan

Credit/Debit card    Check    Cash

Eligibility & Prerequisites

By enrolling, Applicant represents that the following prerequisites are met or will be submitted prior to the first class meeting:

High school diploma or equivalent completed    Applicant is at least 18 years of age at course completion

Current CPR certification (required): Yes    Expiration date:

Immunizations up to date for participation in clinical rotations:

Criminal background check required:

Program Policies, Attendance & Refunds

Attendance: Students are expected to attend all scheduled classroom and clinical sessions. Excessive absences or failure to complete clinical competencies may render a student ineligible to sit for the certification examination. The Program requires documentation for excused absences and reserves the right to require make-up assignments or additional supervised hours.

Certification eligibility: Passing theory and skills assessments and meeting clinical hour requirements are prerequisites to certification exam eligibility. The Program does not guarantee successful certification; the Program will provide instruction and assessment to determine readiness.

Refund/Cancellation policy: Deposits are non-refundable except where the Program cancels a session. If Applicant withdraws prior to the first scheduled class, documented tuition refunds will be considered less the non-refundable deposit and any administrative fees. After course start, partial refunds are applied only in accordance with Program policy and documented pro rata calculations. Fees for mandatory background checks, drug screens, or external clinical requirements paid on Applicant's behalf are non-refundable.

Authorizations, Consents & Release

Background check and drug screening: I authorize the Program and its agents to obtain criminal background information and drug screening results as required by clinical affiliates and licensing authorities. I understand that adverse findings may affect my participation and certification eligibility.

I consent to criminal background check    I consent to drug screening

Clinical placement release: Clinical affiliates may require disclosure of limited student information for placement and credentialing. I authorize release of necessary information, including immunization records and background check results, to clinical partners for purposes of placement.

Liability release and assumption of risk: I acknowledge that participation in clinical and skills-based training involves physical activity and potential exposure to infectious agents and emergency situations. I accept the risks and agree to release, hold harmless, and indemnify the Program, its employees, agents, and affiliates from claims arising from my participation except where caused by gross negligence or willful misconduct of the Program.

I acknowledge and accept the release and assumption of risk clause above

Accommodation & Disability Services

Applicants requesting academic or physical accommodations must notify the Program prior to the first class session. The Program will consider reasonable accommodations consistent with patient safety, clinical requirements, and applicable law. Documentation supporting accommodation requests should be provided.

Certification of Information

By signing below I certify that the information provided on this Enrollment Form is true and complete to the best of my knowledge. I understand that falsification, omission of material facts, or failure to meet prerequisites may result in denial of enrollment, dismissal from the Program, or ineligibility for certification.

I certify that the information provided is complete and accurate

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