Student Registration Please 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 AdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYorkNY County *Choose AlbanyAlleganyBronxBroomeCattaraugusCayugaChautauquaChemungChenangoClintonColumbiaCortlandDelawareDutchessErieEssexFranklinFultonGeneseeGreeneHamiltonHerkimerJeffersonKings (Brooklyn)LewisLivingstonMadisonMonroeMontgomeryNassauNew York (Manhattan)NiagaraOneidaOnondagaOntarioOrangeOrleansOswegoOtsegoPutnamQueensRensselaerRichmond (Staten Island)RocklandSaint LawrenceSaratogaSchenectadySchoharieSchuylerSenecaSteubenSuffolkSullivanTiogaTompkinsUlsterWarrenWashingtonWayneWestchesterWyomingYatesNJ County *Choose AtlanticBergenBurlingtonCamdenCape MayCumberlandEssexGloucesterHudsonHunterdonMercerMiddlesexMonmouthMorrisOceanPassaicSalemSomersetSussexUnionWarrenCounty *Zip Code *Program you are registering for: *SELECTWINCHING & MOVING - West Earl FCFARM T&M RESCUE - Crary Hose / WestfieldFARM C-SPACE AWARENESS - West Hempfield Fire-RescueSILO OPERATIONS - Deer Lake & West BrunswickFARM EMERGENCY AWARENESS - Witmer FCGRAIN BIN RESCUE TECH- Millville FCFARM HAZMAT - Bradford CountySILO AWARENESS - Witmer FCGRAIN BIN RESCUE AWARENESS - Southern Cove VFCSILO OPERATIONS (SAT) - Bradford CountySILO OPERATIONS (SUN) - Bradford CountySILO OPERATIONS - Clinton Twp VFCPlease carefully select the program you are attending.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 *Submit Share:FacebookWhatsAppEmailPrint