General Registration Form Please enable JavaScript in your browser to complete this form.Multiple Choice *EMT ProgramSpecialistMFR (EMR)OtherProgram you wish to register for. If you choose "Other", please indicate class below.If other, what class do you wish to enroll?Name *FirstLastDate of Birth *Drivers License *Please upload a copy of your drivers license if available. * Click or drag a file to this area to upload. Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Gender *MaleFemaleHave you been diagnosed with a disability that could affect your performance during classroom or clinical environment? *YesNoIf yes - please describe your disability:Education: HS Diploma or GED *HS DiplomaGEDA photo copy must be submitted with your application.Please upload a copy of your diploma or GED if available. * Click or drag a file to this area to upload. Immunization Records - TB Screen, Flu, Signed Physical Form * Click or drag files to this area to upload. You can upload up to 10 files. Upload Health Record DocumentsHave you ever been subject to disciplinary action by any Local Medical Control, State, NREMT or other Government body or Professional Organization, including suspension, sanction or revocation of any license or registration? *YesNoIf yes, please explain briefly:Background: Have you ever been convicted of a misdemeanor or felony? *YesNoIf yes, please explain briefly.Application Agreement *I, as listed above, certify that all the information I have entered in this application is correct to the best of my knowledge. I understand that my Registration Fee is non-refundable.My signature below grants permission to the Sanilac Medical Services, Inc., their agents, or assignees to publish, distribute name and/or images, and/or voice recording of the individual named below for any educational, commercial, and artistic purpose. I further understand that this is not limited to only the course I attend, but could be used in future as deemed appropriate by SMS, Inc. I grant these permissions freely and without reservation. *Student SignatureDate *Please state your Unisex Polo Shirt style size (EMT, AEMT Students Only) *SmallMediumLargeX-LargeXXLXXXLXXXXLEmergency Contact Info *Phone *EmailSubmit
