2009 Rope Course Registration

2009 Courses Student Registration If Applicable

Name:

EMT Level:

Address:

EMT Number:

If Applicable

City/Town:

State:

Zip:

Country:

City/Town:

Zip:

Country:

Phone:

Supervisor:

Phone:

Cell:

Email: Department or Agency: Address:

Rope Rescue (Awareness) $125

Rope Rescue (Operations) $210

Confined Space (Awareness) $125

Confined Space (Operations) $425

Fall Protection $65

Multi-Gas Meter (Use & Operations) $ 90

Rope Access (Clinics) $ Fress

Price Total: $

Payment Methods: Payment is accepted by Cash, Check, Money Order, Visa, Master Card, or Department PO. All Checks and Money Orders must be payable to IEME 3 weeks prior to the class. Cash Check # Visa Mastercard PO Name : Card #:

Exp. Date CV Code:

*Rope Rescue & Confined Space Operations classes only In order to be able to attend these programs, the student must show proof of entry level Rope Training or have had Rope Access (Awareness) or Rope Rescue I prior to this Class. All applicants must provide verifiable proof of ID at start of the class and sign all Liability wavers. Students with disabilities will not be rejected. Our efforts will be made to assist those with difficulties as the need arises.

Deposit:

Mail to : IEME International, Inc 24 Briggs Ave. Bourne, MA 02532 USA Questions: Contact Scott Bumpus, FF/EMT-P Training Coordinator @ (339) 502-5050 ext 303 Email: [email protected]