Student Application

Full name *

Address *

Email (Required for confirmation) *

Phone Cell *

Date of Birth

Course Requested *

Date of course requested *

Is your department/service paying for your class? If yes please provide contact person responsible. *

If you are a medical professional and require continuing education hours, please check level of licensure.

License Number and State Issued

NREMT Number *

Emergency contact person name and number *

By signing electronically this application, I have read, understand and agree to the following:

Mid-America Safety Services LLC, reserves the right to refuse training to anyone.

Instructions given by M.A.S.S. is for the sole purpose of instruction for the student attending the class ONLY. All matterial presented is the sole property of M.A.S.S. No videotaping or audiotaping any portion of the class is allowed. We assume no responsibility or liability for any student attending a class who uses any information obtained in the courses to instruct others.

By submitting this form you agree to hold harmless Mid-America Safety Services LLC, its partners and all its employees or contractors from liability from any injuries, sickness or misunderstood instructions. A hard copy of this waiver will be provided the day of training.

All students attending class must be at least 18 years of age unless accompanying a parent (parent must be attending the same class as minor) No students under 12. Courses are planned and instructors are assigned to teach based on sign ups. All payments/deposits are no-refundable, non-transferable unless the student can provide M.A.S.S. with written documentation of an emergency prohibiting the student from attending class. These are approved on a case by case bases.

Instructions given by M.A.S.S. is for the sole purpose of instruction for the student attending the class ONLY. All matterial presented is the sole property of M.A.S.S. No videotaping or audiotaping any portion of the class is allowed. We assume no responsibility or liability for any student attending a class who uses any information obtained in the courses to instruct others.

By submitting this form you agree to hold harmless Mid-America Safety Services LLC, its partners and all its employees or contractors from liability from any injuries, sickness or misunderstood instructions. A hard copy of this waiver will be provided the day of training.

All students attending class must be at least 18 years of age unless accompanying a parent (parent must be attending the same class as minor) No students under 12. Courses are planned and instructors are assigned to teach based on sign ups. All payments/deposits are no-refundable, non-transferable unless the student can provide M.A.S.S. with written documentation of an emergency prohibiting the student from attending class. These are approved on a case by case bases.

By typing my name into the space below I agree to the above. *