Application

EMT Intermediate Course (New Curriculum)

 

Warning: submission of this application indicates that you have read and understand the introductory course material, meet all entry requirements, and are committed to expend the time and energy to successfully complete course requirements.

 

Name:

 

Address:

 

 

 

Email:

 

Phone:

 

Current Ambulance Service:

 

Ambulance Director and phone number:

 

 

Ambulance Medical Director and phone number:

 

 

Number of ambulance runs in the past 12 months where you provided direct patient care:

 

 

The completed Application and your Medical Director’s written recommendation to attend advanced life support training should be mailed to:

 

Jim Upchurch

HC 36 Box 2010

Hardin, MT 59034