NAEMT Student Registration Form

Current NAEMT Program students, please fill out the form below:

NAEMT Program Name *

Please select the program you are taking.

Course Location *

Please input the location where the course is being held.

Name *

First

Last

City, State and Zip Code *

please enter your City, State of Residence and Zip Code

Country

Phone

Email *

Date of Birth

MM/DD/YYYY

National Registry Number *

Please enter your National Registry number to ensure you receive credit for course completion.

National Registry Expiration Date *

State EMS License Number

If the course you are attending is being offered free of charge to Vermont State EMS Providers, please enter your State EMS License Number.

State EMS License Expiration Date

EMS License State

Certification Level *

Username or Email *

Password *

Remember me

PO Box 3101

Burlington, VT 05408-3101

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