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Semester* Please Select Fall 2023Select semester you are registering for

First Name*

Middle Initial

Last Name*

Other Name(s) Used

Address1*Address1

City*City

State*State

Zip*Zip

Phone*

E-mail Address*

Date of Birth*

GenderEnter your gender

Citizenship* Please Select U.S. Permanent U.S. Resident Non-resident alien OtherSelect country of residence

EMS Courses* Please Select Fall 2023 EMT Original - NCCC Saranac Lake Campus -Fall 2023 EMT Refresher - NCCC Saranac Lake Campus Fall 2023 EMT Original - NCCC Malone Campus -Fall 2023 EMT Refresher - NCCC Malone Campus Fall 2023 EMT Original - NCCC Ticonderoga Campus -Fall 2023 EMT Refresher - NCCC Ticonderoga CampusPlease select course

RegistrationStatus

Non-Credit, I am a volunteer member or employee of NYS EMS Agency

Non-Credit, I am not a volunteer member of employee of a NYS EMS Agency

Select Registration Status

Payment Method

My agency or employer we paying for the course

I would like to make payment arrangements

If online payment or check-by-mail is chosen, you will receive an e-mail with instructions on how to proceed after submitting request.

EmployerAgencyPayingPlease provide address if Employer or Agency will be paying for the course.

Verification

I am the individual requesting to be registered for the courses listed above.

I understand, that by signing this registration form, I am formally registered for the above indicated semester and have incurred a financial obligation to pay for these courses unless I formally drop the courses in writing prior to the start of the semester.

Signature*Enter your full name - Parent/guardian signature if registrant is under 18 years of age.

Date*Enter today's Date

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