Kentucky Association of Emergency Medical Technicians ( KAEMT )

Membership Application Form

PLEASE TYPE IN ALL INFORMATION
Please fill out the form and press "print" button when done.

 Mail this form to the address below 

Active/Voting Member: $5.00 (KY EMT-B, FR, EMT-P, EMT-I, RN, LPN, DISPATCHER) 
   Associate Member: $15   Associate Student Member: $15    Corporate/Sponsoring Membership: $50 

Today's Date:- mm/dd/yy    

First Name:

Last Name:

Title:

EMT-B EMT-P EMT-I

LPNRNEMT-FR

EMT-FIREFIGHTERDISPATCHER

Street Address:

Town/City:

State/Province:

Zip Code:

County where you live


County where you work

Work Telephone:

Home Telephone:

Email address: PLEASE PRINT PLAINLY

Membership Type:

(Kentucky Certification - Voting Members)

Active/Voting Membership 

Associate Membership

Associate Student Membership 

Corporate Membership 

Sponsoring Membership               

       ©2000 KAEMT


  

 

                        Employer:

              Select any of the following certifications that apply to your training level:

       AHA CPR                 AAOS Instructor
       AHA CPR Instructor      ASHI Instructor
       ARC CPR                 ARC CPR Instructor 
       ACLS Provider           ACLS Instructor 
       PALS Provider           PALS Instructor
       BTLS Provider           BTLS Instructor
       PHTLS Provider          PHTLS Instructor
       CCEMT-P                 Farm Medic
       Farm Medic Instructor   EMT-C
       ACLS Affiliate          PALS Affiliate
       EMT Instructor          NREMT-I
       NREMT                   NREMT-P
       Firefighter             Firefighter Instructor
       EMT-B                   EMT-P
       EMT-FR                  CEVO Instructor-Ambulance
       other (list)

                     I would like to volunteer with for these committee (s):

Legislative Affairs Committee  Education Committee
Membership Committee           Bylaws Committee
Lobbying                       Olympics
Teaching In-services:          Newsletter
other (list) 



 
 

                     Make Checks payable to:

                Kentucky Association of EMT's
                Mail to:
                Membership Committee

                     P.O. Box 178 

                Elizabethtown, KY  42702