BUTLER COUNTY EMS TEAM REGISTRATION

New Butler County EMS Team members MUST complete this initial program enrollment to be eligible to participate in EMST emergency responses, training courses, and other EMST activities. 

PLEASE NOTE THAT IN ORDER TO ENROLL IN THE EMST YOU MUST HAVE A VALID EMAIL ADDRESS.

Today's Date *
Your FIRST Name: *
Your LAST Name: *
Your Email *
Which Butler County emergency services department are you currnetly affiliated with? (Check all that apply) * Andover Fire/Rescue Dept. Andover PD Atlanta Fire Dept. Augusta Dept. of Public Safety Benton Fire Dept. Benton PD Burns Fire Dept. Disaster Medical Support Unit (Butler Co.) Emergency Communications (Butler Co.) EMS (Butler Co.) Reserve/Volunteer EMS (Butler Co.) Paid Staff Cassoday Fire Dept. CERT (Butler Co.) Douglass Fire Dept. El Dorado Fire Dept. El Dorado PD Emergency Management (Butler Co.) Fronteir Fire Dept. Kansas Medical Center Latham Fire Dept. Leon Fire Dept. PK Safety Potwin Fire Dept. Rescue Squad (Butler Co.) Rose Hill Fire Dept. Rose Hill PD Sheriff's Dept. (Butler Co.) Susan B. Allen Hospital Towanda Fire Dept. Whitewater River Con. Fire Dist. Other
If "Other" please specify
Which BCEMST agency would you like to be considered your primary agency?	*	Select Andover Fire/Rescue Dept. Andover PD Atlanta Fire Dept. Augusta Dept. of Public Safety Benton Fire Dept. Benton PD Burns Fire Dept. Emergency Communications (Butler Co.) EMS (Butler Co.) Reserve/Volunteer EMS (Butler Co.) Paid Staff Cassoday Fire Dept. CERT (Butler Co.) Douglass Fire Dept. El Dorado Fire Dept. El Dorado PD Emergency Management (Butler Co.) Fronteir Fire Dept. Kansas Medical Center Latham Fire Dept. Leon Fire Dept. PK Safety Potwin Fire Dept. Rescue Squad (Butler Co.) Rose Hill Fire Dept. Rose Hill PD Sheriff's Dept. (Butler Co.) Susan B. Allen Hospital Towanda Fire Dept. Whitewater River Con. Fire Dist. Other
What is your CURRENT certification level? * Select Certified First Responder EMT-Basic EMT-Intermediate EMT-I/D MICT EMR (Completed new State certification and have a new card in hand) EMT (Completed new State certification and have a new card in hand) AEMT (Completed new State certification and have a new card in hand) Paramedic (Have a new State certification card in hand) Non-EMS Certified EMST Responder
What is your Kansas Attendant Certification Number? (found on your certification card/enter "NONE" if non-certified) *
What YEAR does your current certification expire? (Enter "NONE" if non-certified) *
Other Comments
Please carefully review all of the information above for accuracy BEFORE pressing the "Submit" button.