<p> CRESTED BUTTE FIRE PROTECTION DISTRICT 2015 EMT-BASIC COURSE APPLICATION</p><p>NAME: ______</p><p>MAILING ADDRESS: ______</p><p>______</p><p>E-MAIL ADDRESS: ______</p><p>PHONE: ______DATE OF BIRTH: ______</p><p>SOCIAL SECURITY NUMBER: ______-______-______</p><p>DRIVER’S LICENSE NUMBER: ______STATE: ______</p><p>PLEASE DESCRIBE ANY MEDICAL TRAINING: ______</p><p>____ 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)</p><p>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</p><p>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.</p><p>IF YOU HAVE ANY QUESTIONS PLEASE FEEL FREE TO CONTACT THE CRESTED BUTTE FIRE PROTECTION DISTRICT AT (970) 349-5333, EXT. 3</p>