Course Name: EMS-203 Emergency Medical Technician Refresher 07-01-2018
Log Number: EMS-203-S035-2021
Class Start Date & Time: 08:00
Class Location: MFRI Headquarters

(Please use complete legal name as shown on your photo identification, for example: Joseph Jay Smith)
(Example: 07-20-1969)
(Example: 123-45-6789)
SID Number available from NFA at:cdp.dhs.gov/femasid/register
If you have forgotten your NFA SID you can find it at:cdp.dhs.gov/femasid/account/find
(Example: 06-01-2021)
(Example: 8811 60th Avenue)
(Example: College Park)
(Example: MD)
(Example: 20742)
(Example: US)
(Example: info@mfri.org)
(Example: 301-226-9900)

If your agency is not listed you must use the paper pre-registration form and submit it to the MFRI regional office managing the course. If you have any questions about the registration process please contact the MFRI SMRTC regional office. Contact information can be found at: https://www.mfri.org/smrtc
Registration for this course requires that you have completed a profile with MIEMSS. This profile can be completed online on the MIEMSS website. Access the website to create your profile at: www.miemsslicense.com
You must complete your profile before the start date for this course.

RELEASE STATEMENT:

In compliance with the federal Family Educational and Rights to Privacy Act of 1974 and the Buckley Amendment, by checking the box below I authorize and give my permission to the University of Maryland, Maryland Fire and Rescue Institute, and the Maryland Institute for Emergency Medical Services Systems to release information concerning my training records to:

  1. the primary instructor of this course;
  2. the local training academy, if this course is being conducted within, or in collaboration with, such academy;
  3. and / or any federal or state agency (Maryland or other) with authority to certify, regulate, and/or fund EMS programs and personnel;

MFRI Course Acknowledgement Statement:

  1. I acknowledge that any fraudulent entry may be considered sufficient cause for rejection or subsequent revocation from this course.
  2. I understand the University of Maryland is not authorized to provide travel, medical, or health insurance for students. I maintain appropriate insurance on an individual basis. I will check my department's insurance policy to determine if I am sufficiently and appropriately covered.
  3. I understand that this registration is not to be regarded as an irrevocable contract between the student and the University of Maryland.
  4. I affirm and declare that I am physically and mentally fit to perform all tasks within this course.
Check box to acknowledge that you have read the statements above.

MFRI Operations Rules and Regulations:

You are required to read the MFRI Operations Section Rules and Regulations and then check the box.


Check box to acknowledge that you have read the MFRI Operations Section Rules and Regulations
By checking this box I give permission for MFRI to provide my contact information with the Maryland State Firemen's Association so they can provide me with information about benefits that are available to me.

If you do not check the box above your information will not be shared with the Maryland State Firemen's Association. To learn more about the benefits that are available to you from the Maryland State Firemen's Association visit their web site at: www.mdvolunteers.org