CHECK ONE: CORE REFRESHER_______ ELECTIVE(S)__________
NAME:___________________________
VOLUNTEER EMS AGENCY: _____________________
(If applicable)
ADDRESS: _______________________________________________________________________
(Please include zip code)
COUNTY: ______________ COURSE SITE: ___________________ BIRTHDATE:_______________
I.D. or S.S. NUMBER:_____________________ COURSE START DATE:____________________(Required)
TELEPHONE NUMBER: (DAY) ___________ (NIGHT)_______________ BEEPER #____________
The undersigned verifies that:
1. All of the information above is true and accurate.
2. The EMT listed above is a member or prospective member of a volunteer
ambulance, first aid or rescue squad and is eligible for reimbursement of
EMT training expenses in accordance with N.J.A.C. 8:40A.
Verified by: ____________________________ Title:_____________________________________
(Principal Officer's Signature-Original signatures only-no photocopy)
Principal Officer's Name (Printed):_____________________________ Date Signed_____________
NOTICE: IT IS A CRIME FOR ANY PERSON TO KNOWINGLY OR WILLFULLY PROVIDE FALSE INFORMATION ON THIS APPLICATION, OR MAKE DELIBERATELY MISLEADING STATEMENTS REGARDING THE ELIGIBILITY OF APPLICANTS (NJSA 2C:21-4 (a) ).
PARENT/GUARDIAN CONSENT: (For minors 16 & 17 years of age)
My son/daughter has permission to attend the EMTB class being sponsored by the 14th District of the New Jersey State First Aid Council. I agree to assist him/her in abiding by the regulations as promulgated by the New Jersey State Department of Health & Senior Services - Office of Emergency Medical Services and/or the 14th District. Also, I understand that the smoking policy of the 14th District does not allow smoking by minors without express permission of their parent/guardian and, understanding this, I (circle one) agree/do not agree to allow my son/daughter to smoke at 14th District classes.
PARENT/ LEGAL GUARDIAN SIGNATURE:__________________________________________
DATE:____________________________
