Do you live in the United States?
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Zip Code/Postal Code
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What name would you like to appear on the completion certificate
if blank, your first name and last name above will be used
If you have a UVM NetID, please enter below.
Past UVM students have a Net ID. A 'Net ID" is a UVM identifier that combines your first initial and last name. E.g. for "Joe Thompson" the net id would be "jthompso"
Highest Level of Education Completed
For research purposes only
How did you hear about this program?
If you have dietary restrictions, please list below
We want to serve you a meal that meets your dietary needs
In what year do/did you expect to complete your undergraduate degree?
Are you taking the self-paced or in-person class?
When would you like to receive access to the online MCAT prep program?
Date must be after the 20th of the current month
Students with affiliation, please enter your Vermont EMS Service License number:
Please check below to indicate your agreement with the release and waiver of liability
I agree to the release and waiver of liability below.
RELEASE AND WAIVER OF LIABILITY: As a condition of accompanying rescue personnel on fire apparatus or ambulances, I hereby acknowledge and assume full responsibility for any physical injuries and/or other damage(s) that may occur while I am a voluntary occupant in such vehicles or while I am at the scene of any emergency or non-emergency situation with rescue personnel. I fully understand that when rescue personnel dispatches equipment in response to a fire, rescue or other crisis call that it means that rescue personnel are responding to a potentially hazardous situation which may result in my (or, in the case of a passenger between the ages of 16 and 18, my child's) exposure to known and unknown hazards. I understand that this includes exposure to and/or use of Fire apparatus/ambulance equipment that may break, malfunction or be used improperly by the operators of that equipment. I agree to immediately and fully obey all lawful requests and commands of the fire apparatus/ambulance organization leader and shall not participate in any medical treatment or care unless specifically requested by the assigned leader. I also understand that I may be exposed to certain confidential information. Accordingly, I will not reveal the identity of individuals, discuss the incidents with third parties or write about the incidents without the express written consent of the officers of the fire apparatus/ambulance organization. I agree to hold UVM, the fire apparatus/ambulance organization, and its officers, employees, and agents free and harmless from any liability, claims, suits or damages of whatever kind or nature that may be occasioned by the above-described events and waive any right of subrogation I may have. Such release shall not apply if liability for injury or damage arises from the gross negligence of UVM, the fire apparatus/ambulance organization or their officers, employees, and agents.
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