Eastern Huron Ambulance Service
Group Leader Enrollment Form
Name:*
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Last Name Required
Email:*
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License Type (Select From Dropdown Menu):*
License Type (Select From Dropdown Menu) is Required
EMR/MFR
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AEMT
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State Issued (Select From Dropdown Menu):*
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Rhode Island
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Tennessee
Texas
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Washington
West Virginia
Wisconsin
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Other
State EMS # (Required for CAPCE and State CE):
State EMS # (Required for CAPCE and State CE) is not valid
Date of expiration (Month day, year)(Required with State EMS #):
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NREMT # (Leave BLANK if none. This means, do not put any abbreviations or words in this field. Simply leave the field empty if you do not have an NREMT number.):
NREMT # (Leave BLANK if none. This means, do not put any abbreviations or words in this field. Simply leave the field empty if you do not have an NREMT number.) is not valid
NREMT Re-registration Date (Required if NREMT # is provided):
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Agency Name (Providing the agency name does not automatically enroll you in the agency account.):
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Your City of Residence:*
Your City of Residence is Required
State of Residence (Select From Dropdown Menu):
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgina
Washington
West Virginia
Wisconsin
Wyoming
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Zip Code:*
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Username:*
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Email:*
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Password:*
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This site collects names, emails and other user information and never sells user information. By agreeing to this policy, you consent to the terms set forth in the
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. If you are taking CAPCE accredited courses, you additionally understand that American CME will submit a record of your CAPCE course completions to the CAPCE AMS. You further understand that course completion records may be accessed by or shared with such regulators as state EMS offices, training officers, and NREMT on a password-protected need-to-know basis. In addition, you understand that you may review your record of CAPCE accredited course completions by contacting CAPCE.
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