EMT Class Application

Please fill out the following application for the EMT Class.

Student Info:

First Name: *

Last Name: *

Street Address: *

City/Town *

State

Zip Code

Date of birth (ex. 01/02/2003) *

Email: *

Phone: *

Emergency Contact Info

Emergency Contact Full Name: *

Emergency Contact Phone: *

Previous Medical Training

Payment Options

Please select resident type below and either mail payment (checks or cash ONLY) or drop off by September 30th, 2024 to:

Monroe Volunteer Emergency Medical Service
54 Jockey Hollow Road
Monroe, CT 06468

Choose one

Resident - $800

Non-resident - $950

Textbook Type *

Physical

Digital

Shirt Size

Class fees include the cost of the textbooks.
Funds are non-refundable after the start of the program.
Students who successfully complete the program and receive State certification and become an active volunteer may be eligible for a refund of the class fee.

Thank you for your info. Please mail payment to Monroe Volunteer Emergency Medical Service 54 Jockey Hollow Road Monroe, CT 06468 by September 30, 2024.

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