AEMT/EMTI Interest List

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We are using this application to gather information and ensure there is enough student interest to hold this class.

We have a class with a full waiting list starting in January 2023, but if enough people are interested in a future class we will look into when it can be scheduled.

Verified commitments will be required before the training will be scheduled.

STUDENT INFORMATION

Much of this information is used to create a student roster to submit to the State of Oregon, so please fill it out completely.

First Name: *

Last Name: *

Middle Initial:

Street Address: *

City: *

Zip Code: *

Email Address: *

Phone Number *

Approve Texts *

If the Phone Number provided is a cell phone do you approve of EMS Programs communicating via text messaging?

Yes

Training Interest Level *

How committed to this training are you at this time?

Slighting interested in information.

Extremely, I need this training!

TRAINING/TESTING/LICENSE INFORMATION

Birth Date: MM/DD/YYYY *

State of Oregon EMT License # *

State of Oregon EMT License is required for training. NREMT is not acceptable.

Training Fee Payment:

This training is not for credit and does not qualify for Financial Aid and there are no scholarship opportunities offered through Lane. You will have to verify ahead of time to ensure this training meets any requirements for student loan deferment or outside funding sources. It does not meet the requirements for an IRS Form 1098-T.

Payment Method: *

If you are paying for your training, you will be sent a link to make an online payment via card 4-8 weeks before the training starts.

I am paying for my training

I am being sponsored by an agency who will be paying for my training

Agency Affiliation:

Please let us know what agencies you are affiliated with. If your training is being sponsored by an agency, please indicate which agency will be paying.

Location and Travel

We have interest in this training from all over the state, and we would like to check on the viability of two classes this year.

Where are you located?

Are you available to commute to Eugene multiple times a week?

Yes, I am able to travel to Eugene for weekday evenings and weekends

No, I would be able to travel to Eugene on weekends, but not during the weekdays

No, I would not be able to travel to Eugene every week

Other:

License Training Level

Let us know which license levels you were prefer, as some may not be interested in our standard combo course.

AEMT/EMTI combo works for me

AEMT only

EMTI only, I am already a licensed AEMT

Other:

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Lane Community College. Report Abuse

Forms