EMS & Trauma Education
Registration Form


Name Professional level:
Address Date
  Last 4 digits SSN
  EMS ID#
E-mail Day phone
Affiliation Eve phone
Send acknowledgment via   (  ) e-mail    or    (  ) U.S. postal mail? Cell phone

Select your preferred method to deliver course materials:
(  ) Pick-up at RWJUH EMS Education, 126 Paterson Street in New Brunswick, Monday-Friday 8:30 a.m. to 4:30 p.m. (Recommended if registering within 2 weeks of course.)
(  ) US mail to above address.  (This may take as much as 10 days, even locally.)

Course Title Course Date(s) Tuition/Fees
    $
Enter optional date(s) for ACLS ECG/pharmacology reviews or other skills sessions, if appropriate:

$
Check #                 is enclosed.  Make check or money order payable to "Robert Wood Johnson University Hospital."
Cancellation Refunds:  RECEIVED less than ten BUSINESS DAYS before the course--NO REFUND.  Ten or more business days--full refund if issued material(s) are returned in brand new condition prior to the start of the course.
Total $
For Credit Card Payment Only
Card Type (check one):   [ ]American Express    [ ]MasterCard     [ ]VISA     [ ]Discover Card
Cardholder's Name  
Card Number  
Expiration Date  
Please read and sign below this statement:  I agree to pay the total amount noted above per the card issuer agreement.

Cardholder's Signature:


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Registration Checklist
  1. All fields on registration form are complete.
  2. CPR card is attached for courses listed on the form.
  3. Valid ACLS or PALS card are attached for their respective renewals.
  4. RWJUH New Brunswick employees have completed and attached our special form (available internally).
  5. If using the NJ EMT Training Fund, the form bearing the ORIGINAL SIGNATURE from an eligible agency is attached.
  6. If paying via credit card, cardholder has signed.
  7. Mark the course date(s) on your calendar!
Registration, Refund and Cancellation Information

 Register by fax or mail

Using the NJ EMT Training Fund