FMTI Critical Care Paramedic Course

Registration Form

 

Last Name: __________________________   First Name: ___________________ Middle: ____

 

Degree: (check one)      ¨ EMT-P       ¨ RN      ¨ MD/DO      ¨ RT    

 

Affiliation/Department: __________________________________________________________

 

Address: _____________________________________________________________________

 

City: ___________________________________ State: __________ Zip: _______________

 

Phone #:___________________   Cell #: ___________________   Fax #:___________________

 

E-Mail Address: _______________________________________________________________

 

CCEMT:  Course Dates:

 

   Orlando @ Rural Metro Ambulance

¨CCEMTP-008 (1) November 17^th, 18^th, December 1^st, 8^th, 9^th, 15^th, 16^th,

 January 5^th, 12^th, & 19^th Exam January 27^th

¨CCEMTP-008 (2) November 19^th, 20^th, December 3^rd, 10^th, 11^th, 17^th, 18^th,

January 7^th, 14^th, 21^st, Exam January 28^th

 

 

Credentials:  (Please include copies with your application)

p EMT-P/NREMT-P   p RN   p BLS/CPR   p ACLS

p PALS/PEPP/PPC      p BTLS/PHTLS/TNCC/ATLS

 

PRE REGISTRATION 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:                                       Credit Card Information:

Florida Medical Training Institute

                                                                                                                                Card Type:  p Visa p MC p Amex

Mail To:                                                                                

FMTI                                                                                                                      Card #________________________

CCEMT Registration

5575 S. Semoran Blvd Suite 34

Orlando, FL 32822                                                                                                                                                               

 Exp. Date: _________________

                Or

                                                                                                                                Name on Card: _______________

Fax To: (407) 275-9640

                                                                                                                                Signature: ________________________

Rev. 08/08