Student Registration

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Name

First

Middle

Last

Department / Agency

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Address

City

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State

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Date of Birth

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Program you are registering for:

By signing 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 put your initials in the text field below to acknowledge.

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