EMS class registration form

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You will receive a call from a class representative confirming registration and to answer any questions you may have.

Name *

Age *

16-18

over 18

Street Address *

City *

Phone number *

email address *

Why do you want to become an EMT?

Do you have any healthcare or public safety experience?

Are you interested in doing an observation shift prior to the start of class?

Yes

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How do you plan on paying your non refundable deposit? *

Cash or Check dropped off at our station at 835 Beaver Drive in DuBois

Check mailed to our station at PO BOX 253, DuBois, PA 15801

Paid by credit card. https://pay.balancecollect.com/m/amservltd

You will receive a confirmation email or upon receipt and processing of your registration form. Please note, class size is limited and your seat will not be held until the deposit is received. Any questions please either call Dawn Buck at 814-375-9290 ext 7020 or email at dmb.training@amservdusan.com

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