Please enable JavaScript in your browser to complete this form.Dropdown ItemsHybrid EMT Initial Certification Course - $1,500.00Name *FirstMiddleLastAge Selected Value: 16 Please provide your ageDate of Birth *mm/dd/yyyyEmail *Address, number and street *City or Town *State *Zip Code *Are you affiliated with an EMS organization or agency? *NoYesWho will be paying for the course? *AgencyStudentCourse slots are not guaranteed until payment is received in full.Payment by Invoice or Credit Card *InvoiceCredit CardCourse slots are not guaranteed until payment is received in full.Name of Agency * Please provide the name of your organization or agency.Agency Contact Name *Please provide the name for a point of contact at your agency.Agency Contact Phone Number *If you are affiliated with a VT EMS service or Law Enforcement Agency, please provide the phone number of the agency contact. (XXX)-XXX-XXXXAgency Contact Email *EmailConfirm EmailStudents are required to provide payment in full to secure a seat in the course prior to the course start date. Full payment is preferred, but payment plans may be considered on a case-by-case basis following special approval from NETS Ownership. Full refunds will be issued if course is dropped prior to the start date. No refunds will be granted after the start date. Students who wish to withdraw after the start date, but within 4 weeks of class start date are eligible to attend another EMT course tuition free but will not receive a refund *I understandBy clicking "I Understand" you are indicating you are accept the terms above. Total$0.00Stripe Credit Card *CardName on CardSubmit