EMT Registration Form

Semester*Select semester you are registering for

First Name*

Middle Initial

Last Name*

Other Name(s) Used

Social Security Number*

Address1*Address1

City*City

State*State

Zip*Zip

Phone*

E-mail Address*

Date of Birth*

GenderEnter your gender

Citizenship*Select country of residence

EMS Courses*Please select course

RegistrationStatus

AEMT Original - Non-Credit ($1,250)

AEMT Refresher - Non-Credit ($625)

EMT Original - Non-Credit ($950)

EMT Refresher - Non-Credit ($475)

Students who would like to enroll in EMT courses as credit college students will need to complete the Non-Matriculated Credit Registration Form https://www.nccc.edu/registration/non-degree-seeking-registration.html . Please contact records@nccc.edu for more information on how to register for credit based courses.

NYSEMSAgencyAffiliation

I am currently a member of a NYS EMS Agency (NYS Funding Eligible)

I am not currently a member of a NYS EMS Agency

Select NYS EMS Agency Affiliation Status

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