First Name *

Last Name *

Phone *

Email *

DOB

Street Address *

State *

City *

Postal Code *

What are your goals for becoming an EMT?

Tell us what brought you here and what you hope to do with your training. Where would you like to work—for example, a fire department, ambulance service or hospital?

EMS experience and CPR/BLS certifications

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Previous EMS experience or training

EMS, CPR or BLS certifications

No prior EMS training is required. Leave blank if none.

Clinical rotation connection

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Clinical rotation site or organization

Take your training into the real world. Clinical rotations give you the opportunity to learn alongside local EMS and emergency-department teams. Already have a connection with an ambulance service, fire-based EMS agency or emergency department? Share their details below so we can help coordinate your clinical experience. No connection yet? You can leave this section blank and provide those details later.

Clinical contact name

Clinical contact phone

Clinical contact email

Emergency contact

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Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

Tuition Payment Plan *

When would you like to start? *

Your first tuition payment is due on this date. Course access begins after payment is confirmed.

ENROLLMENT AGREEMENT & FINANCIAL RESPONSIBILITY

By checking this box and signing below, I acknowledge that I am enrolling in a course offered by Rapid Response Safety Training and agree to the total tuition associated with the program in which I enroll. I understand that I am financially responsible for any unpaid tuition balance, including in the event of withdrawal, dismissal, or non-completion, subject to Rapid Response Safety Training’s published refund and withdrawal policy.

I understand that my electronic acknowledgment and signature are intended to constitute my signature and agreement to these enrollment terms.

Enrollment Agreement *

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I consent to receive non-marketing text messages from Rapid Response Safety Training related to my enrollment, account, course, payment, onboarding, scheduling, and other services I have requested. Message frequency may vary. Message & data rates may apply. Reply HELP for help or STOP to opt out.

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