NTCC EMS Program Application

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NTCC EMS Program
Student Application

Personal Information

Last Name:

First Name:

Middle Name:

Preferred Name:

Street Address:

City:

State:

Zip Code:

Home Phone:

Mobile Phone:

Email:

Date of Birth:

Education History

Highest level of formal education acheived:

In which YEAR was the highest level of education achieved?

Are you currently admitted to NTCC?

Have you taken the TSI Exam?

Have you taken any prior courses here at NTCC?

In which EMS Program are you interested?

In which Semester?

Are you interested in any other NTCC Program(s)?

Work History

Are you currently employed?

Do you think there will be any potential conflict with your Employer regarding the extensive amount of hours of dedicated training needed here for the EMS Program?

Have you been in the Military or Reserves?

Physical Evaluation

Do you have a history of or currently have any of the following? Mark YES or NO (If yes, please Explain)

Back Injury or Back Pain

Physical Impairments/Deformities

Diabetes

Heart Problems

High Blood Pressure

Stomach/Digestive Issues

Asthma or Lung Disorders

Sinus, Food or Skin Allergies

Anaphylaxis

Epilepsy, Seizures, Fainting

Psychological Problems Requiring Medications

Learning Disabilites

Smoking or Tobacco Use

Alcohol or Substance Abuse

ANY reaction to "shots" or medicine?

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