Name: ________________________________________

Soc. Sec. #: ________________________

Address: ___________________________________________________

City: __________________________________

State: ________________ Zip: ________________

Home Phone: ___________________________

Work Phone: ______________________________

Birth Date: _______________________________

Course Name: _____________________________________________

Course Location: _________________________________________

Course Start Date: _________________

Agency Affiliation: _________________________________________

PLEASE READ:

Tuition support from NYS/EMS can only be provided for active members of EMS agencies which have a PCR agency code and participate in the PCR system.

Students who are not affiliated with an EMS agency by the start date of the class are NOT eligible for tuition support from NYS/EMS.

Tuition support will only be provided for students who pass the State (re) certification exam when taken on the scheduled test date for the course which he/she is registered. A student who fails or does not test on the original scheduled date will receive a tuition bill issued by the MCC Bursar’s Office and is obligated to pay the tuition. A reimbursement from the Bursar’s Office will be issued when (re)certification is obtained within one year of the original test date.

For a reservation, complete and return this form by fax, (585-279-4150), or mail (above address, Attn: Karen Wilson). For more information, call 585-279-4011.