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EMT Application & Registration
* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student Email Address- please use an email not given to you by your school.
*
Your answer
Student Cell Phone Number xxx-xxx-xxxx
*
Your answer
Address (Street, City, State, Zip)
Your answer
Date of Birth - Student must be 16-18 years old to take this course
*
MM
/
DD
/
YYYY
Your Grade Level this Fall
*
Grade 9
Grade 10
Grade 11
Grade 12
Your High School
*
Choose
Arcola HS
Arthur LAH HS
Beecher City HS
Casey-Westfield HS
Charleston HS
Chrisman HS
Cowden-Herrick HS
Cumberland HS
Dieterich HS
Effingham HS
Kansas HS
Marshall HS
Martinsville HS
Mattoon HS
Neoga HS
Oakland HS
Okaw Valley HS
Paris Co-op HS
Shelbyville HS
Shiloh HS
St. Anthony HS
Stew-Stras HS
Sullivan HS
Teutopolis HS
Windsor HS
Parent/Guardian Name (First and Last)
Your answer
A Parent Phone Number
Your answer
A Parent Email
Your answer
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This form was created inside of Eastern IL Education for Employment System 340.
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