EMR Driver Class Application

Please fill out the following application for the EMR Driver Class.

Full Name: *

Address: *

Email: *

Phone: *

Valid Driver's License Number: *

State Issued: *

Emergency Contact Full Name: *

Emergency Contact Phone: *

Please select and mail payment (checks preferred) in the amount below by February 15th, 2023 to:

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

Resident - $150.00

Non-Resident - $300.00

Class fees do not 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

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