RescueTechs Student Registration Form RescueTechs Student Registration FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.First Name *Middle Initial / Name *Last Name *Date of Birth *It is easiest to select your year of birth first.Department / Agency Affiliation: *PhoneEmail *EmailConfirm EmailPlease note that we only ask for your email address to communicate with you specifically regarding the class that you are attending. RescueTechs does not share, sell, etc. your email address to anyone outside of our business. (We hate spam, too!!!)Address *City *State *ChoosePennsylvaniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPA County *Choose N/AAdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYorkDE County *Choose KentNew CastleSussexNY County *Choose N/AAlbanyAlleganyBronxBroomeCattaraugusCayugaChautauquaChemungChenangoClintonColumbiaCortlandDelawareDutchessErieEssexFranklinFultonGeneseeGreeneHamiltonHerkimerJeffersonKings (Brooklyn)LewisLivingstonMadisonMonroeMontgomeryNassauNew York (Manhattan)NiagaraOneidaOnondagaOntarioOrangeOrleansOswegoOtsegoPutnamQueensRensselaerRichmond (Staten Island)RocklandSaint LawrenceSaratogaSchenectadySchoharieSchuylerSenecaSteubenSuffolkSullivanTiogaTompkinsUlsterWarrenWashingtonWayneWestchesterWyomingYatesNJ County *Choose N/AAtlanticBergenBurlingtonCamdenCape MayCumberlandEssexGloucesterHudsonHunterdonMercerMiddlesexMonmouthMorrisOceanPassaicSalemSomersetSussexUnionWarrenVA County *Choose N/AAccomackAlbemarleAlexandriaAlleghanyAmeliaAmherstAppomattoxArlingtonAugustaBathBedfordBlandBotetourtBristolBrunswickBuchananBuckinghamBuena VistaCampbellCarolineCarrollCharles CityCharlotteCharlottesvilleChesapeakeChesterfieldClarkeColonial HeightsCovingtonCraigCulpeperCumberlandDanvilleDickensonDinwiddieEmporiaEssexFairfaxFairfax CityFalls ChurchFauquierFloydFluvannaFranklin CountyFranklin-CityFrederickFredericksburgGalaxGilesGloucesterGoochlandGraysonGreeneGreensvilleHalifaxHamptonHanoverHarrisonburgHenricoHenryHighlandHopewellIsle Of WightJames CityKing And QueenKing GeorgeKing WilliamLancasterLeeLexingtonLoudounLouisaLunenburgLynchburgMadisonManassasManassas ParkMartinsvilleMathewsMecklenburgMiddlesexMontgomeryNelsonNew KentNewport NewsNorfolkNorthamptonNorthumberlandNortonNottowayOrangePagePatrickPetersburgPittsylvaniaPoquosonPortsmouthPowhatanPrince EdwardPrince GeorgePrince WilliamPulaskiRadfordRappahannockRichmond CountyRichmond-CityRoanoke CountyRoanoke-CityRockbridgeRockinghamRussellSalemScottShenandoahSmythSouthamptonSpotsylvaniaStaffordStauntonSuffolkSurrySussexTazewellVirginia BeachWarrenWashingtonWaynesboroWestmorelandWilliamsburgWinchesterWiseWytheYorkLA ParishChooseAcadiaAllenAscensionAssumptionAvoyellesBeauregardBienvilleBossierCaddoCalcasieuCaldwellCameronCatahoulaClaiborneConcordiaDeSotoEast Baton RougeEast CarrollEast FelicianaEvangelineFranklinGrantIberiaIbervilleJacksonJeffersonJefferson DavisLafayetteLafourcheLasalleLincolnLivingstonMadisonMorehouseNatchitochesOrleansOuachitaPlaqueminesPointe CoupeeRapidesRred RiverRichlandSabineSaint BernardSaint CharlesSaint HelenaSaint JamesSaint John the BaptistSaint LandrySaint MartinSaint MarySaint TammanyTangipahoaTensasTerrebonneUnionVermilionVernonWashingtonWebsterWest Baton RougeWest CarrollWest FelicianaWinnCounty *Zip Code *Program you are registering for: *SELECTAgricultural Hazardous MaterialsBasic Vehicle RescueElectric VehiclesEMS Continuing EducationFarm Safety and Emergency AwarenessFarm Tractor and Machinery ExtricationGrain Bin Rescue Awareness LevelGrain Bin Rescue Technician LevelGrain Bin Rescue RefresherHeavy Vehicle RescueRope RescueSilo Fire and Emergency AwarenessSilo OperationsFarm Confined Space Emergency AwarenessVehicle Rescue RefresherPlease carefully select the program you are attending.Class Location *Date of Class (1st Day of class if multiple days) *Are you a PA emergency medical services provider (EMR, EMT, etc.)? *SELECTYESNOMany RescueTechs programs, but not all, are approved for PA EMS continuing education credits. Your instructor will let you know if this program has EMS approved con-ed credits assigned. If this program does have credits, they will be uploaded to the EMS database with 10 days of successful completion of the program. What is your certification level?EMREMTAEMT, Paramedic, PHRN, etc.What is your certification number?By initialing below, I certify that I am a bona-fide member of my agency/department and is covered by workman’s compensation and liability coverage by this agency. RescueTechs LLC, the program instructors, and the host agency (if other than my own) assume no liability for injuries or deaths that occur as part of this training program. Please initial in the text field below to acknowledge.Student Initials *Please press the submit button once and allow the system to process your entry. You will receive a confirmation email shortly.Submit Share:FacebookWhatsAppEmailPrint