Use this form if you or your employer will be sending a check with your registration.
If you wish to pay by credit card or bank transfer, use the on-line registration for MD/DO/PA/NP, for RN, or for EMTP.

Please return this form with your payment to:

EMSTAR
1058 West Church Street
Elmira, NY 14905

The fee schedule is printed below. Refunds will not be made without written notification at least 10 business days in advance. All course materials will be mailed to you upon receipt of your registration form and payment. We look forward to serving your training needs!

Name ______________________________      __ RN     __MD/DO/PA/NP      __Paramedic      __ Other

Address ___________________________________   Telephone __________________________

City/State/Zip __________________________    E-Mail Address ___________________________

Organization Affiliation ________________________  Medical Specialty ______________________

Amount enclosed _____________________      Please check one:    __ Initial Training     __ Renewal

Course and date or which you are registering:

Course: ___________________________________     Date: ______________________________

For more information please (607) 732-2354 ex 105 or e-mail ksmith @ emstar.org

Program Coordinator: Robert Rajsky, M.S. Ed., AHA Regional Faculty (southerntieracls @ aol.com)
(607) 732-2354 ex 101 or (607) 331-3158

All course materials will be mailed directly to you upon receipt of your registration form and payment.

NOTE: Although these courses are not sponsored by any AHA component, some or all materials utilized by students or faculty may be AHA materials.