Student Registration Form
FireTech Training Student Registration Form
Full Name (First and Last) *
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Todays Date *
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Student Phone Number *
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Students Email Address *
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Last 4 digits of the students Social Security Number *
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Date of Birth *
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Students Mailing Address *
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City, State and Zip code *
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Students Fire/EMS Position/Rank *
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EMS state license number *
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Sponsoring Department (This is who is paying for your class) *
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Department mailing address *
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City/State/Zip code *
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Chiefs name *
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Chiefs phone number *
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Chiefs email address *
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Course Name *
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Course Payment Method *
Purchase Order Number (If Applicable)
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*Cancelation Policy* if you wish to cancel your registration for a program, you must cancel 72 hours before the class start date. Failure to do so will result in the registrant to pay for the class in full (as advertised cost) to FireTech Training with in 30 days or your account will be submitted to collections. *
*Refund Policy* To obtain a full refund from any class registered, you must email KRomano@FireTechTraining.com with in 72 hours of the start date of the registered class. If you have any questions or need to make arrangements please do not hesitate to contact us. *
*TERMS OF ACCEPTANCE and SIGNATURE* The student for this registration, warrant the truthfulness of the information provided in this application.Electronic Signature. *Please type your First and Last Name in the line below* *
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I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. *
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Notes
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