Clone of EMT Course Registration Form

1
Student Name* This field is required.
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2
Birth Date* This field is required.
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Day
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3
Gender* This field is required.M, F, X
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Male
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4
Address* This field is required.
Street Address
Street Address Line 2
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Afghanistan
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5
County (Not Your Country)* This field is required.Example: Bronx, Kings, Queens, New York, Westchester, Putnam, Dutchess, Rockland
6
Student E-mail* This field is required.
7
Mobile Number* This field is required.DEMO: ### #######
Area Code
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8
State Photo ID* This field is required.
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Course Start Dates* This field is required.Choose Your Desired Start Date
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Please Select
BLS Original - 09/01/2026 - 9:00AM - Bronx
BLS Renewal - 09/01/2026 - 9:00AM - Bronx
ACLS Original - 09/01/2026 - 1:00PM - Bronx
ACLS Renewal - 09/01/2026 - 1:00PM - Bronx
BLS Original - 09/02/2026 - 9:00AM - Bronx
BLS Renewal - 09/02/2026 - 9:00AM - Bronx
ACLS Original - 09/02/2026 - 1:00PM - Bronx
ACLS Renewal - 09/02/2026 - 1:00PM - Bronx
BLS Original - 09/03/2026 - 9:00AM - Bronx
BLS Renewal - 09/03/2026 - 9:00AM - Bronx
ACLS Original - 09/03/2026 - 1:00PM - Bronx
ACLS Renewal - 09/03/2026 - 1:00PM - Bronx
BLS Original - 09/04/2026 - 9:00AM - Bronx
BLS Renewal - 09/04/2026 - 9:00AM - Bronx
ACLS Original - 09/04/2026 - 1:00PM - Bronx
ACLS Renewal - 09/04/2026 - 1:00PM - Bronx
BLS Original - 09/05/2026 - 9:00AM - Bronx
BLS Renewal - 09/05/2026 - 9:00AM - Bronx
ACLS Original - 09/05/2026 - 10:00AM - Bronx
ACLS Renewal - 09/05/2026 - 10:00AM - Bronx
BLS Original - 09/06/2026 - 9:00AM - Bronx
BLS Renewal - 09/06/2026 - 9:00AM - Bronx
PALS Original - 09/06/2026 - 10:00AM - Bronx
PALS Renewal - 09/06/2026 - 10:00AM - Bronx
BLS Original - 09/07/2026 - 9:00AM - Bronx
BLS Renewal - 09/07/2026 - 9:00AM - Bronx
ACLS Original - 09/07/2026 - 1:00PM - Bronx
ACLS Renewal - 09/07/2026 - 1:00PM - Bronx
BLS Original - 09/08/2026 - 9:00AM - Bronx
BLS Renewal - 09/08/2026 - 9:00AM - Bronx
ACLS Original - 09/08/2026 - 1:00PM - Bronx
ACLS Renewal - 09/08/2026 - 1:00PM - Bronx
BLS Original - 09/09/2026 - 9:00AM - Bronx
BLS Renewal - 09/09/2026 - 9:00AM - Bronx
ACLS Original - 09/09/2026 - 1:00PM - Bronx
ACLS Renewal - 09/09/2026 - 1:00PM - Bronx
BLS Original - 09/10/2026 - 9:00AM - Bronx
BLS Renewal - 09/10/2026 - 9:00AM - Bronx
ACLS Original - 09/10/2026 - 1:00PM - Bronx
ACLS Renewal - 09/10/2026 - 1:00PM - Bronx
BLS Original - 09/11/2026 - 9:00AM - Bronx
BLS Renewal - 09/11/2026 - 9:00AM - Bronx
ACLS Original - 09/11/2026 - 1:00PM - Bronx
ACLS Renewal - 09/11/2026 - 1:00PM - Bronx
BLS Original - 09/12/2026 - 9:00AM - Bronx
BLS Renewal - 09/12/2026 - 9:00AM - Bronx
ACLS Original - 09/12/2026 - 10:00AM - Bronx
ACLS Renewal - 09/12/2026 - 10:00AM - Bronx
BLS Original - 09/13/2026 - 9:00AM - Bronx
BLS Renewal - 09/13/2026 - 9:00AM - Bronx
PALS Original - 09/13/2026 - 10:00AM - Bronx
PALS Renewal - 09/13/2026 - 10:00AM - Bronx
BLS Original - 09/14/2026 - 9:00AM - Bronx
BLS Renewal - 09/14/2026 - 9:00AM - Bronx
ACLS Original - 09/14/2026 - 1:00PM - Bronx
ACLS Renewal - 09/14/2026 - 1:00PM - Bronx
BLS Original - 09/15/2026 - 9:00AM - Bronx
BLS Renewal - 09/15/2026 - 9:00AM - Bronx
ACLS Original - 09/15/2026 - 1:00PM - Bronx
ACLS Renewal - 09/15/2026 - 1:00PM - Bronx
BLS Original - 09/16/2026 - 9:00AM - Bronx
BLS Renewal - 09/16/2026 - 9:00AM - Bronx
ACLS Original - 09/16/2026 - 1:00PM - Bronx
ACLS Renewal - 09/16/2026 - 1:00PM - Bronx
BLS Original - 09/17/2026 - 9:00AM - Bronx
BLS Renewal - 09/17/2026 - 9:00AM - Bronx
ACLS Original - 09/17/2026 - 1:00PM - Bronx
ACLS Renewal - 09/17/2026 - 1:00PM - Bronx
BLS Original - 09/18/2026 - 9:00AM - Bronx
BLS Renewal - 09/18/2026 - 9:00AM - Bronx
ACLS Original - 09/18/2026 - 1:00PM - Bronx
ACLS Renewal - 09/18/2026 - 1:00PM - Bronx
BLS Original - 09/19/2026 - 9:00AM - Bronx
BLS Renewal - 09/19/2026 - 9:00AM - Bronx
ACLS Original - 09/19/2026 - 10:00AM - Bronx
ACLS Renewal - 09/19/2026 - 10:00AM - Bronx
BLS Original - 09/20/2026 - 9:00AM - Bronx
BLS Renewal - 09/20/2026 - 9:00AM - Bronx
PALS Original - 09/20/2026 - 10:00AM - Bronx
PALS Renewal - 09/20/2026 - 10:00AM - Bronx
BLS Original - 09/21/2026 - 9:00AM - Bronx
BLS Renewal - 09/21/2026 - 9:00AM - Bronx
ACLS Original - 09/21/2026 - 1:00PM - Bronx
ACLS Renewal - 09/21/2026 - 1:00PM - Bronx
BLS Original - 09/22/2026 - 9:00AM - Bronx
BLS Renewal - 09/22/2026 - 9:00AM - Bronx
ACLS Original - 09/22/2026 - 1:00PM - Bronx
ACLS Renewal - 09/22/2026 - 1:00PM - Bronx
BLS Original - 09/23/2026 - 9:00AM - Bronx
BLS Renewal - 09/23/2026 - 9:00AM - Bronx
ACLS Original - 09/23/2026 - 1:00PM - Bronx
ACLS Renewal - 09/23/2026 - 1:00PM - Bronx
BLS Original - 09/24/2026 - 9:00AM - Bronx
BLS Renewal - 09/24/2026 - 9:00AM - Bronx
ACLS Original - 09/24/2026 - 1:00PM - Bronx
ACLS Renewal - 09/24/2026 - 1:00PM - Bronx
BLS Original - 09/25/2026 - 9:00AM - Bronx
BLS Renewal - 09/25/2026 - 9:00AM - Bronx
ACLS Original - 09/25/2026 - 1:00PM - Bronx
ACLS Renewal - 09/25/2026 - 1:00PM - Bronx
BLS Original - 09/26/2026 - 9:00AM - Bronx
BLS Renewal - 09/26/2026 - 9:00AM - Bronx
ACLS Original - 09/26/2026 - 10:00AM - Bronx
ACLS Renewal - 09/26/2026 - 10:00AM - Bronx
BLS Original - 09/27/2026 - 9:00AM - Bronx
BLS Renewal - 09/27/2026 - 9:00AM - Bronx
PALS Original - 09/27/2026 - 10:00AM - Bronx
PALS Renewal - 09/27/2026 - 10:00AM - Bronx
BLS Original - 09/28/2026 - 9:00AM - Bronx
BLS Renewal - 09/28/2026 - 9:00AM - Bronx
ACLS Original - 09/28/2026 - 1:00PM - Bronx
ACLS Renewal - 09/28/2026 - 1:00PM - Bronx
BLS Original - 09/29/2026 - 9:00AM - Bronx
BLS Renewal - 09/29/2026 - 9:00AM - Bronx
ACLS Original - 09/29/2026 - 1:00PM - Bronx
ACLS Renewal - 09/29/2026 - 1:00PM - Bronx
BLS Original - 09/30/2026 - 9:00AM - Bronx
BLS Renewal - 09/30/2026 - 9:00AM - Bronx
ACLS Original - 09/30/2026 - 1:00PM - Bronx
ACLS Renewal - 09/30/2026 - 1:00PM - Bronx
10
How Did You Hear About Us?* This field is required.
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11
TransportationHow do you plan to commute to class most days?
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12
Quick Notes For Office
13
Course Payment Description: (Signature Required)* This field is required.Here is a clean, professional, and transparent Payment Description & Policy Page for your website. It breaks down the exact costs, deposit requirements, and cash balances so students know precisely what to expect when registering. Course Pricing & Payment Information At Code One Inc., we keep our registration process straightforward and accessible. To reserve your seat in any of our American Heart Association (AHA) courses, a non-refundable deposit is required online at checkout. Your remaining balance is due in cash at the office on the day of your class. 💳 Course Fee Breakdown 🩺 Basic Life Support (BLS / CPR) Original Course:$100 Total $20 Non-Refundable Deposit (Paid Online Now) $80 Remaining Balance (Paid in Cash at Office) Renewal Course:$65 Total $20 Non-Refundable Deposit (Paid Online Now) $45 Remaining Balance (Paid in Cash at Office) 🫀 Advanced Cardiovascular Life Support (ACLS) Original Course:$200 Total $100 Non-Refundable Deposit (Paid Online Now) $100 Remaining Balance (Paid in Cash at Office) Renewal Course:$165 Total $100 Non-Refundable Deposit (Paid Online Now) $65 Remaining Balance (Paid in Cash at Office) 👶 Pediatric Advanced Life Support (PALS) Original Course:$225 Total $100 Non-Refundable Deposit (Paid Online Now) $125 Remaining Balance (Paid in Cash at Office) Renewal Course:$180 Total $100 Non-Refundable Deposit (Paid Online Now) $80 Remaining Balance (Paid in Cash at Office) 📌 Payment Policy Details ⚠️ Important Policy Notes for Students Seat Reservation: Your seat is only locked in once your online deposit is completed. Deposit Policy: All online deposits ($20 for BLS; $100 for ACLS/PALS) are strictly non-refundable. Day-of-Class Balance: The remaining balance MUST be paid in CASH upon arrival at our training center prior to the start of class. Please bring exact change whenever possible. Rescheduling: If you need to reschedule your course, please notify our team at least 48 hours in advance to transfer your deposit to a future date.
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Card Holder ID UploadUpload ID of Card Holder Required if payer is not student named above (If this does not apply please proceed to next slide)
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Card Holder SignatureCard Holder Signature Required if payer is not student named above (If this does not apply please proceed to next slide)
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Course Payments* This field is required.DEPOSIT REQUIRED (REMAINING CASH PAYMENTS DUE DAY OF CLASS)
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AHA BLS COURSE DEPOSIT
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AHA ACLS / PALS Course Deposit
NON REFUNDABLE DEPOSIT. (TRANSFERRABLE) REMAINING PAYMENT DUE IN CASH PRIOR TO THE START OF THE COURSE
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