EMS Education Course Registration Form

EMS Education Course Registration Form

This form is your first step toward joining the ranks of Prometheus Foundry’s EMS programs: EMR, EMT, or Paramedic. A $100 registration fee (non-refundable, goes towards tuition) reserves your place for review. Once your registration has been received and approved, our admissions team will send you a link to complete your full enrollment package and finalize your seat in the program.
Personal Information
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I am UNDER 18 years old:*

Yes (<18)No
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile Number*
Please enter a valid phone number.
Select the course you are registering :*
EMT or AEMT License #
EMS License Expiration Date

MonthDayYear
Date
Polo Shirt Size*
I am a military veteran or reservist

YesNo
Upload proof of service (DD-214, ID card)

Cancelof
How did you hear about us:*
Other:*
Staff Member Referral Name:*
Student Referral Name:*

Terms and Conditions
Students applying to this course must be able to present:
- Valid state or US government-issued picture ID
- High school diploma or GED
- Proof of immunization including documentation of either receiving the required vaccine or a titer showing immunological response OR
- State-approved vaccination exemption form
  * The minimum required immunizations include Hepatitis B, TDAP, Tuberculosis, MMR, Influenza, and Varicella. Some clinical sites may require proof of COVID-19 vaccination.
2. All prospective students must pass a criminal background check and urine drug screen. Students will not be enrolled if they fail to meet the requirements of the NREMT or of Texas DSHS.

3. The registration fee is non-refundable. This fee secures your seat in the course and covers administrative costs. No refunds of the Course Registration Fee will be provided.

4. Failure to submit the full course tuition/deposit by the specified payment deadline will result in the forfeiture of the reserved seat and the non-refundable registration fee.

5. Completion of this course is for educational and certification purposes only and does not guarantee employment or job placement assistance.

6. By registering, the student confirms they meet all stated prerequisites for this EMS course. Falsification of prerequisite documentation will result in immediate dismissal without a refund.
Signature*

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Date*

MonthDayYear
Date

My Products*

EMS Course Registration Fee Product Image

EMS Course Registration Fee

$100.00 Quantity
Item subtotal:$0.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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