ALL FIELDS ARE MANDATORY

EMS Refresher Application

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ALL FIELDS ARE MANDATORY

TO MAKE PAYMENTS PLEASE CALL 216-523-7040, PRESS "0" TO PROCESS PAYMENT. ALL FORMS OF CREDIT OR DEBIT CARDS ARE ACCEPTED.

1.	First Name:*

2.	Last Name:*

3.	Home Street Address*

4.	City*

5.	State*

6.	Zip Code*

7.	Phone *

8.	E-mail Address:* THIS IS THE PRIMARY MEANS OF REGISTRATION AND COMMUNICATION.

9.	30hr EMT, 40hr Advanced or 48hr Paramedic* Please select the refresher you are interested in taking.

10.	Please enter the name of your Fire Department, EMS Service or place of employment/affiliation.*

11.	Please select the online session you wish to enroll in.*

12.	Please select the Approved Skills Verification Center you wish to attend to complete the psychomotor objectives (skills) of the refresher. The selected SVC will contact you to schedule a time Note some Regional SVCs may not be availible durring all sessions, depending on staffing

13.	Please select the Skills Check-Off date you wish to attend * * The skills date you choose must corrispond with session you are enrolled in

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