CMH EMS Education Application Form
The permanent link to this form is http://www.ozarksems.com/education-application.php

A lot of good info can be found on our website to answer your questions about EMS classes at CMH. Or you can email theron.becker@citizensmemorial.com
Your first name: *
Your answer
Your last name: *
Your answer
Your email address (this is our primary means of communicating with students): *
Your answer
Agency you belong to (not required but helpful):
Your answer
Your cell phone number with text messaging (this is our secondary means of communicating with students) [optional]:
Your answer
Which course are you enrolling in? *
If you pick "Other - Not Listed," above, what is the name of the course?
Your answer
What is the start date of the course? *
MM
/
DD
/
YYYY
What is the start time of the course? *
Time
:
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: *
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.
Your answer
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