Susquehanna Emergency Health Services Council

 249 Market St.
Sunbury, PA 17801
570-988-3443
Fax 570-988-3446

                          

SEHSC - EMS Training Program
Online Student Information Request

By filling out the form below and then submitting it, your form will be processed for the upcoming EMS Training Program sponsored by the Susquehanna EHS Council. We may contact you by mail, phone or Internet email for further details. In addition, you will be contacted for payment arrangements. Please provide as much information as possible. You can also apply by calling Laura Rompolski at the SEHSC council office at 570-988-3443 or sending an e-mail to secretary@sehsc.org

When filling out the form, use the TAB key or your mouse to go to the next data area. Use the scroll bar to scroll down the form.

Your First Name:
Your Middle Initial:
Your Last Name:
Your Email Address:
Your Date of Birth:   ( mm / dd / yyyy )
Social Security No:   ( 123-45-6789 )
Street Address 1:
Street Address 2:
City:
State:
Zip code:
Telephone:
County of residence:

Class Desired:

 Level of Class:
Regional EMS Council:
EMS Primary Affiliation (ambulance/QRS/fire company):

To Register For a Program, Choose The Drop-Down Menu Next To The Items You Want 
(EMT Classes Only First Responder skip to the bottom)

    

Student tuition includes a $75.00 HACC registration and a $55.00 SEHSC lab fee.  Purchase of workbook is optional.
All prices subject to change without notice. 

Text/tuition fees due at first class session.
Checks payable to: SEHSC.  Receipts will be issued.
   
Brady - Emergency Care 10th Edition (Textbook & Workbook)
   		     Combo Pack for $80.00
   
Brady - Emergency Care 10th Edition (Textbook Only)
 		     Textbook Only $60.00
   
Brady - Emergency Care 10th Edition (Workbook Only)
 		     Workbook Only $30.00
   
I Will Be Paying for Tuition Only
 		     Tuition for $130.00
    
   

Terms  

I understand that by submitting this form only temporarily holds me a place in the program I have selected.  I also understand that total payment must be received no later than deadline and only then is my place secure. I further understand that I may cancel prior to the registration deadline and I will receive a total refund.  However, I will not be funded for cancellations the deadline.  If I need to cancel, I understand I can substitute another individual.


IF YOU AGREE TO THE TERMS, PLEASE TYPE YOUR FULL NAME HERE       


 If needed, please include any additional comments or questions here:

This information collected in this form is for the sole purposes of the above. The information may be shared with subcontractors of the council and/or state. However, no names or other personal information will be disclosed without explicit permission.

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Susquehanna Emergency Health Services Council, Inc. is an equal opportunity provider of contracts, grants, employment and service.
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