EMS Continuing Education Registration Form

* = required field

Some content may be updated based on selection

EMS Continuing Education Registration Form
903-434-8269 or emsp@ntcc.edu

Student Information

NTCC Student ID: if known

SSN:

Date of Birth:

Last Name:

First Name:

Middle Initial:

Nickname:

Current Address:

City:

State:

ZIP:

Primary Phone:

Type:

Home

Cell

Work

Alternate Phone:

Type:

Home

Cell

Work

Email: (the one you check most frequently)

Educational Interest:

Personal Enrichment:

Improve Job Skills:

Demographic Information

The following information is used for federal and/or state reporting purposes and to help provide support for our programs.
Your answers are completely voluntary and will be kept strictly confidential.

Please Select One:

Male

Female

Decline to Answer

Please Select One:

Native American/Alaskan

Hawaiian/Pacific Islander

White

Asian

Black/African American

Hispanic/Latino

Non-Hispanic/Latino

Decline to Answer

Please Select One:

Paramedic

Advanced EMT

EMT Basic

Emergency Medical Responder

MIH Course

Registration - office use only

Course Name & Number

Days/Times

Start Date

Tuition/Fees

EMR

Payment Method

Cash:

Check:

Credit Card:

Company Invoice or Credit Card:

Bill TRMC:

*Make checks payable to Northeast Texas Community College. Driver's license must be on the check.

Refund Policy: A 100% refund if the "drop" form is completed before the first class day. 80% refund if comleted before the 2nd class day.
No refund after 2nd class day. Students must contact the Continuing Education office to withdraw.

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