Please enable JavaScript in your browser to complete this form.Dropdown ItemsHybrid EMT Initial Certification CourseHybrid AEMT Initial Certification CourseName *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? *NoYesWho will be paying for the couse? *AgencyStudentCourse 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, 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, subject to a 10% processing fee, will be issued if a student wishes to withdraw or rescind their registration prior to 48 hours of the start date of the course. Partial refunds (50% of total course cost) will be issued if a student wishes to withdraw or rescind their registration within 48 hours of the start date of the course. Students who wish to withdraw after the start date, but within 3 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 agree to and are accepting of the terms above. Total$0.00Stripe Credit Card *CardName on CardSubmit