SPRING 2012 EMT-BASIC COURSE

PLEASE PRINT ALL INFORMATION CLEARLY AND SIGN ALL THREE SECTIONS OF THIS FORM
INCOMPLETE AND UNSIGNED FORMS WILL BE RETURNED AND NO SEATS IN THE PROGRAM WILL BE RESERVED.
STUDENTS MUST BRING STATE / GOV’T. ISSUED IDENTIFICATION ON THE FIRST NIGHT OF CLASS.

LAST NAME __________________________ FIRST NAME___________________ MIDDLE INITIAL _____

HOME ADDRESS_______________________________________________________________

CITY ____________________________ STATE ____ ZIP ________________

D.O.B. _______________ SSN# _______________DRIVERS LICENSE # _____________

PHONE (H) _______________ (W) ________________________ (CELL) _________________

EMAIL ADDRESS ___________________________________________________

APPLICANT STATEMENT
I hereby certify that I have not been convicted of a crime involving moral turpitude within the past three years,
nor am I addicted to the use of drugs or alcohol.

SIGNATURE OF APPLICANT _______________________________DATE ________________

FINANCIAL RESPONSIBILITY AGREEMENT
Total tuition is payable on or before the first day of class. Tuition is $625 for non-Stratford residents, $525 for Stratford residents, $325 for full-time youth students age 16 – 18, $275 for Active members of Stratford EMS and/or Explorer Post 4911 members. Tuition includes course fees, books, and CPR card. Cancellation policy: 100 percent tuition refund if written notice of withdrawal is received by the last business day prior to the first day of class, 50 percent refund if written notice of withdrawal is received through the first 14 calendar days of the course, no refunds granted after the 14th day. There is a $40 fee for all returned checks.

SIGNATURE OF APPLICANT ____________________________ DATE ________________

SIGNATURE OF GUARDIAN / FINANCIALLY RESPONSIBLE PARTY (if under 18 years old) ___________________

WAIVER OF LIABILITY
I understand that I am being instructed by members of the Stratford Volunteer Emergency Medical Services Association, Inc, under the guidelines of the State of Connecticut Department of Public Health Emergency Medical Technician (EMT) training protocols. I also understand that the skills learned and put to use by me as an EMT will be regulated by my licensure with the State of Connecticut. I will not hold liable any employee, officer or agent of the Stratford Volunteer Emergency Medical Service Association, Inc. for any misuse of the skills learned through this educational program. I will also not hold liable any employee, officer or agent of the Stratford Volunteer Emergency Medical Service Association, Inc. for any injuries that I may receive while under the normal instruction of the syllabus of this course or while practicing and / or performing the practical application of said skills.

SIGNATURE OF APPLICANT________________________________________DATE________________________

For Office Use Only: Date application received_________________Payment________________Method______________