Westchester County Department of Emergency Services

EMS Registration Form

Upon completion of this form, you will receive an automated acknowledgement of your request to register. Please review the form to assure its accuracy and keep this form for your records. You will be notified of the status of your enrollment in a separate email.

Westchester DES reserves the right to cancel classes as necessary.

Please Provide The Following

Agency:

 

Other:

If your agency doesn't appear in the list above. please email emsedu@westchestergov.com to have your agency added. Thank you!

IMPORTANT! You must include a valid email address

Requested By:		 Contact  Phone:  
 

FAX:
E-Mail:  


COURSE:


            Please check for any       eligibility requirements

Some courses have maximum numbers of students allowed. You will be notified of the status of your enrollment in a separate email. In the event you are "wait listed" notification of  additional availability will be made via email only.

Student #1    Provider  Type:  
Student #2  Provider  Type:
Student #3 Provider  Type:
Student #4  Provider  Type:
Student #5  Provider Type:

Please add any additional comments, questions or explanations below:

Westchester County Department of Emergency Services.
Copyright © 2000, 2004.  All rights reserved.
Revised: July 15, 2008