EMS/EMT Registration - NMSU-A

New Mexico State University Alamogordo/Continuing Education
EMS/EMT Courses
NON-CREDIT REGISTRATION FORM
PERSONAL INFORMATION
Name:
LAST
FIRST
MI
Mailing Address:
STREET or P.O. BOX
Phone:
CITY
STATE
ZIP CODE
Email Address:
HOME
CELL
BILLING INFORMATION
eBlast Reminders: YES / NO
Name of Party/Counselor Responsible for Payment:
Self
WIA
DVR
Other
Mailing Address:
STREET or P.O. BOX
Phone:
CITY
STATE
ZIP CODE
Email Address:
DAYTIME
EVENING
Course # / Title:
Cost: $
START DATE
Course # / Title:
Cost: $
START DATE
Course # / Title:
Cost: $
START DATE
Course # / Title:
Cost: $
START DATE
Total: $
For more information on the class, contact Cynthia Osborne, Interim Director for EMS at (575) 491- 0088
To Register: call NMSU-A Continuing Education at (575) 439-3842 for Non-credit, NMSU-A Advising at (575) 439-3720 for Credit
Make checks payable to ACE or NMSU-A.
Call (575) 439-3842 to pay over the phone
Mail to:
Continuing Education | NMSU-A
2400 N. Scenic Dr. Room 401
Alamogordo, NM 88310
Academic programs at NMSU-A are available to all students without regard to age, ancestry, color, disability, gender, national origin, race, religion, sexual orientation, or veteran status.
New Mexico State University ofrece programas educativos, actividades, materiales sin discriminación basada en edad, color, discapacidad, identidad o expresión de identidad sexual,
origen nacional, raza, religion, sexo, orientación sexual, o estado de veterano.
Title IX and 504 Coordinator: Jeremy Patton 575-439-3703 [email protected] ASD Coordinator: Viviane Ackall 575-439-3724 [email protected]
The Annual Security and Fire Safety Report is available on the NMSU-A campus website at http://nmsua.edu/welcome.
You can pick up a copy at the Office of Facilities, 2400 North Scenic Drive or you can request that a hard copy be mailed to you by calling 439-3600.
Confirmation sent ____emailed____hard copy
Date:________________________________