EMT Application

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MCC Emergency Medical Services Training

Note: All of the fields marked with an asterisk (*) are required.

Student Information

First Name:

Last Name:

Previous Name:
(if applicable)

Date of Birth:

Email Address:

Daytime Phone:

Street Address:

City:

State/Province:

County:

Zip/Postal Code:

Agency Affiliation:
(if applicable)

Gender:

If you do not know your CRN #, please refer to the Course Schedule webpage.

Course Reference Number / CRN:

Semester:

Previously Attended MCC?

Citizenship:

What is your race? (select one or more)

American Indian / Alaskan Native

Black or African American

Asian

Native Hawaiian / Pacific Islander

White

Are you Hispanic / Latino?

Tuition support from NYS/DOH can only be provided for active members of EMS agencies, which have a PCR agency code, and participate in the PCR system. Students who are not affiliated with an EMS agency by the start date of the class are NOT eligible for tuition support from NYS/DOH. State funding is contingent upon continued availability of funds.

NYS DOH tuition support will only be provided for students who pass the State (re)certification exam when taken on the scheduled test date for the course, which they are registered. A student who fails or does not test on the original scheduled date will receive a tuition bill issued by the MCC Student’s Account Office and is obligated to pay the tuition. A reimbursement from the Student Accounts Office will be issued when (re)certification is obtained within one year of the original test date. Matriculated students can apply for financial aid.

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EMT Application

MCC Emergency Medical Services Training

Student Information

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