RVESCUE Course Registration

*First Name:

*Last Name:

*Address 1:

*City:

*State:

*Zip:

*Home Phone:

Cell Phone:

*Email:

*Agency/Organization:

Are you a member of the NJ EMS Task Force?
YES
NO

Certification Level:

Certification # (For EMT's add Cert ID #)

*Register For:

Prerequisites:

By signing up for CEVO Ambulance Manuevers, I certify that:
1) I have a valid US drivers license.  
2) I am aware that if partipating in the 2nd day that I will supply my own agencies vehicle for use during course
3) My agency will supply a Certificate of Insurance naming RVESCUE, LLC, the instructors and location of training as additional insureds for the day of the course
4) That there will be a $25 cancellation fee for any enrolled student not finishing the course.
5) Pay fees listed on the course page, or supply paperwork as required for reimbursement

*Date of Course:

*Course Location:

Fee:

*Eligibility/Payment:

*Verification:
By clicking this box, I agree that I have signed up for this course, have completed any requirements for the training program requested, will supply any required equipment listed in the course description, have the necessary insurance to cover me during this training event, and understand that a $20 fee will be charged if I do not complete any course I enroll in.

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