EmailMe Form - UH EMS Institute EMT Refresher Registration

EMT refresher dates you would like to participate in. *
1-16-23 through 3-20-23
4-10-23 through 6-10-23
9-12-23 through 12-4-23
Name *
First Last
Are you affiliated with a direct UH Med Command Department, EMS Agency or UH Medical Center? *
Yes
No
Your Department, EMS Agency or Medical Center Affiliation. If none, submit N/A *
This field is for you to enter the department, EMS agency or medical center you are affiliated with. If you are not affiliated type in N/A (not applicable)
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Email *
Date of Birth *
MM / DD / YYYY
Phone *
### - ### - ####
You must upload a copy of your EMT card in one of the accepted formats. *
Your image file can not exceed one megabyte.
You must upload a copy of your BLS Provider card in one of the accepted formats. *
Your image file can not exceed one megabyte.
eSignature and agreement *
By enrolling and signing via esignature, you agree to enrollment of the UHEMS Institute online refresher. If you do not complete the refresher, a $100.00 administrative fee will be charged to you, or your dept as applicable.
Image Verification

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