Crested Butte Fire Protection District

CRESTED BUTTE FIRE PROTECTION DISTRICT 2015 EMT-BASIC COURSE APPLICATION

NAME: ______

MAILING ADDRESS: ______

______

E-MAIL ADDRESS: ______

PHONE: ______DATE OF BIRTH: ______

SOCIAL SECURITY NUMBER: ______-______-______

DRIVER’S LICENSE NUMBER: ______STATE: ______

PLEASE DESCRIBE ANY MEDICAL TRAINING: ______

____ DO YOU HAVE A CURRENT HEALTHCARE PROVIDER CPR CARD? ____ ARE YOU INTERESTED IN VOLUNTEERING WITH THE CRESTED BUTTE FIRE PROTECTION DISTRICT? ____ ARE YOU A FULL-TIME RESIDENT RESIDING WITHIN THE CBFPD? (THE CBFPD SPANS ABOUT 220 SQ. MILES AND INCLUDES THE TOWNS OF CRESTED BUTTE AND MT. CRESTED BUTTE)

TO RESERVE YOUR SEAT, PLEASE RETURN THIS APPLICATION WITH YOUR COURSE TUITION OF $800.00 TO: CRESTED BUTTE FIRE PROTECTION DISTRICT 306 MAROON AVENUE P.O. BOX 1009 CRESTED BUTTE, CO 81224

INCLUDED IN YOUR $800 TUITION IS THE $119.95 EMT-B TEXTBOOK, CLINICAL CREDENTIALING, AND UNIFORM SHIRT. THE TUITION DOES NOT INCLUDE ADDITIONAL STATE AND NATIONAL CERTIFICATION FEES.

IF YOU HAVE ANY QUESTIONS PLEASE FEEL FREE TO CONTACT THE CRESTED BUTTE FIRE PROTECTION DISTRICT AT (970) 349-5333, EXT. 3