FMTI Pediatric Neonatal Critical Care Transport
Registration Form
Last Name: _________________________ First Name: _____________________ Middle: __
Degree: (check one) ¨ EMT-P/NREMT-P ¨ RN ¨ MD/DO ¨ RT
Affiliation/Department: __________________________________________________________
Address: _____________________________________________________________________
City: ___________________________________ State: ___________ Zip: _______________
Phone #:___________________ Cell #: ___________________ Fax #:___________________
E-Mail Address: _______________________________________________________________
PNCCT & NRP: Course Dates:
p February 16th-27th, 2009(PNCCT) Mon-Fri Orlando $950.00
p February 20th, 2009 (NRP) Fri Orlando $150.00
p October 5th-16th, 2009(PNCCT) Mon-Fri Jacksonville $950.00
p October 9th, 2009 (NRP) Fri Jacksonville $150.00
** NRP is required for the course and is an additional fee. If a student already has NRP, he/she will not have to attend the NRP class.
Credentials: (Please include copies with your application)
p EMT-P/NREMT-P p RN ¨ MD/DO ¨ RT
p PALS/PEPP/PPC p NRP p BLS CPR
PREREGISTRATION IS MANDATORY
Payment Policy
A deposit of $200.00 must be submitted with the registration to hold a position in the course. The balance is due 14 prior to the course start date.
Refund/Cancellation Policy
All cancellations & request for refunds must be made in writing 45 days prior to the course start date.
FMTI reserves the right to cancel class if minimal enrollment is not meet. In the event of cancellation, tuition will be refunded or transferred to another course date at FMTI's expense.
Make Checks/Money Orders payable to:
Florida Medical Training Institute
Mail To:
FMTI
PNCCT Registration
Attn: Laura Muno
Phone (321) 751-9696 Fax (321) 751-4747
Credit Card Information:
Card Type: p Visa p MC p Amex
Card #________________________
Exp. Date: _________________
Name on Card: ________________
Signature: ___________________