Department of Transportation EMT and EMT-Paramedic Refresher Courses by sparkunder13

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									                     Department of Transportation EMT and EMT-Paramedic Refresher Courses
                                                    This Form is for Rural Metro Employees Only

                                                John S Holloway, Course Coordinator and Lead Instructor
                                                        P.O. Box 564 ♦ Seymour, TN 37865-0564
                                                               Telephone: 901.734.0242
                                                   No refunds. Courses missed may be re-scheduled.

                                Contact John S Holloway @ Cordinator2@bellsouth.net if further information is needed

                                           Participants must attend all days listed. No partial credit is awarded

                     _____     DOT EMT-Basic/TN EMT-IV Refresher                    8AM – 5PM            (Registration Deadline 23 NOV 2007)
                               December 8, 9, 10, and 14, 2007                      Includes AHA CPR Renewal

                     _____     DOT EMT-Paramedic Refresher                          8AM – 5PM            (Registration Deadline 23 NOV 2007)
                               December 8, 9, 10, 14, 15, and 16, 2007              Includes AHA ACLS Renewal


                           Please legibly PRINT or type the following course registration information

          Name: ______________________________________________________________________
                        Last                         First                        MI

          Last 4 digits of SS #: _____________                 Date of Birth: ___________-_______- ________
                                                                                  Month       Day       Year
          Home Street
          Address: ____________________________________________________________________

          City/State/Zip Code:___________________________________________________________

          Email Address: ______________________________________________________________
          Please provide email address only if you wish to be added to an email notification list of medical related courses. This list will not be shared, sold,
          or traded and will be used for educational purposes only.

          Phone: Home: ______________________________ Work: __________________________

          Employer: __________________________________________________________________

          Assignment/Department/Shift: _________________________________________________

          Prior BTLS/ITLS Course Completion Date: ____________                      _____ N/A

          Prior Pediatric BTLS/ITLS Course Completion Date: ___________                        _____ N/A

          Certification/Licensure Level: ____ MD _____ RN _____ EMT-P ____ EMT-B/IV ____ RT                                 Other ___________

          NREMT #: _________________________                             State: _____          Expiry: _____________________

          State License #: _________________________         State: _____                      Expiry: _____________________
                        Do not put the 0’s in front of number


Course Disclaimers: By participating in this course the participant acknowledges and agrees to the conditions as described herein and below:
COURSE COMPLETION: Course completion is defined as successful demonstration of the core knowledge on said date and neither guarantees nor
implies whether implicitly or explicitly a guarantee of successful future performance. The Training Center, Facilitator, Coordinator and or Instructor(s) do not
guarantee future performance therefore by participating in this activity the participant hereby indemnifies and holds the aforementioned harmless from any
claims as may arise from participation this activity or activities. The participant furthermore agrees and understands that comprehension and performance is
an individual responsibility, and that the sponsoring organization does not license or certify individuals in skills or procedures. The participant must adhere to
local standing orders, protocols, or other medical direction, and within the individual’s scope of practice.

								
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