Course Pre-Registration
Agency Form

Please complete this form if your agency will be sending more than one student to class.
This is a pre-registration only, it does not confirm placement into the class.

Rescue 3 International Students: Once your payment is received for any Rescue 3 classes, you will received an email or phone call confirming receipt of payment and your confirmation.

Please complete the form below to pre-register for the course you would like to attend.

When you are finished, please click the "Submit Registration" button. You will receive an email confirmation of your pre-registration and information how to submit your payment for our courses.

Agency Contact Information:
(This is the person who will handled the registration process for your agency)

Class Type:  
Class Name:  
Class
 Location:		  
Class Dates:  
Agency Name  
Agency Type:  
Agency Contact Name:  
Agency Contact's
E-Mail:		  

Agency Contact's
Home Phone

  

Agency Contact's
Cell Phone:

  

Please list the participants that will be attending from your agency below.
 

Student Information:     

First/Last Name  Address City State Zip First
Time
Student		 Recertifying
Student		 Class
Assistant
       
       
       
       
       
       
       
       
       
       

If you have additional members, please submit this form, then open the registration form again and re-submit additional members.