CMH EMS Education Application Form
The permanent link to this form is
A lot of good info can be found on our website to answer your questions about EMS classes at CMH. Or you can email
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Your first name:
Your last name:
Your email address (this is our primary means of communicating with students):
Agency you belong to (not required but helpful):
Your cell phone number with text messaging (this is our secondary means of communicating with students) [optional]:
Which course are you enrolling in?
Academy - Emergency Medical Responder (EMR)
Academy - Emergency Medical Technician (EMT)
Academy - Paramedic
NAEMT - All Hazards Disaster Response (AHDR)
NAEMT - Geriatric Education for EMS (GEMS)
NAEMT - Pre-Hospital Trauma Life Support (PHTLS)
NAEMT - PHTLS Refresher
NAEMT - Psychological Trauma in EMS Patients (PTEP)
NAEMT - Tactical Combat Casualty Care (TCCC)
NAEMT - Tactical Emergency Casualty Care (TECC)
Other - Field Training Officer
Other - EMS Instructor
Other - Hazmat Medic
Other - Life Support Competency
Other - Safety Seminar
Other - Not Listed
If you pick "Other - Not Listed," above, what is the name of the course?
What is the start date of the course?
What is the start time of the course?
Definition of "Partner Agency" used in the following question
A partner agency is described as an agency that has primary or mutual aid responsibilities in CMH EMS districts or to CMH facilities.
Pick the category that describes you the best:
CMH employee (enter your employee number below)
Volunteer of partner agency
Member of partner agency (career)
None of the above apply
If you are a CMH employee, enter your employee number here. By entering your number, you agree to having the application fee payroll deducted if you are no-call, no-show to class. Written notice of dropping the class must be obtained two weeks prior to class.
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