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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