EMT In-Person Academy Post Checkout Form 1

Student Registration

Step 1

Confirm Student Information

Step 2

Review Terms & Conditions

Step 3

Choose Payment Option

Step 4

Review Registration Info

Step 1

Step 2

Step 3

Step 4

Confirm Student Information

Document

Student's Name and Information

First name*

Middle Initial

Last name*

Date of birth*

Photo ID

Please upload a copy of your state issued photo ID (Driver's License)*

Student's Address

Where we will send your textbooks.

Street Address*

City *

State *

Postal Code

Email*

Phone number*

Mobile phone number

Anticipated Course Start and Completion Dates

Anticipated Start DateDate you would like to begin the course.

Anticipated Completion DateYou must complete the course within 9 months of your start date.

Textbook Options*Choose the textbook option you prefer (note: e-book option only includes the textbook and not workbook. e-book only accessible by internet and not in downloadable form. e-book access ends after 1 year)