EMS Academy Course Request Form

Please fill out the following form to request a course affiliated with the EMS Academy. Please submit your course request 60 days in advance of course start date. Beginning March 1, 2017 course requests received less than 45 days in advance of start-date are subject to a $500.00 expediting fee along with the regular approval process. A course request is considered submitted on the day that the EMS Academy receives it with no missing components.

Requestor Name

Requestor Phone Number

Phone

Requestor Email Address

Is this a credit class being offered through a branch or partner campus?

Yes

Course Type

Initial Licensure

CE Package

Proposed Course Start Date

mm/dd/yyyy

Time frame of proposed course

Completed if there is not a firm start date planned or if start date is left blank.

Proposed Class Schedule

Can upload planned class schedule, hous calculation, or anything else that has been prepared for this request.

Drop your files here

Comments

Explain anything here not noted in the questions answered above that needs to be considered for this class (virtual component requested, etc.).

I agree to follow the rules and policies for this Academy course and understand that by not agreeing to this, this course will not be approved.

Send me a copy of my responses

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