RescueTechs Student Registration Form

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First Name

Middle Initial / Name

Last Name

Date of Birth

Department / Agency Affiliation:

Phone

Confirm Email

Address

City

County

State

Zip Code

Program you are registering for:

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