EMS Pharmacology, Research, & Critical Care Paramedic Application

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EMS Pharmacology, Research, &
Critical Care Paramedic Application

Complete all fields. If a field is not applicable, enter "N/A".

Course Selection

Select the course(s) you are applying for this semester:

EMSP 2206 EMS Pharmacology

EMSP 2352 EMS Research

EMSP 2358 Critical Care Paramedics

Personal Information

First Name:

Last Name:

MI:

Social Security Number

Date of Birth

Age

Mailing Address:

City:

State:

Zip:

Home Phone Number

Cell Phone Number

Drivers License Number

Drivers License State

Student Email Address

Level of Certification: EMT / AEMT / Paramedic

State or NR#

Education

HIGH SCHOOL/GED

High School

Graduation Year

High School City:

High School State:

Do you have a GED?

Yes

COLLEGE

List all colleges or universities attended, graduation year, and degree obtained:

TECHNICAL TRAINING

List technical training, graduation date, and degree obtained:

MILITARY SERVICE

Branch

Service Dates

Specialty

Discharge Type

If other than Honorable, please explain.

General Information

Emgerency Contact

Emergency Contact Name

Relation

Cell Phone Number

Home Phone Number

Do you have any issues that may impact your ability to physically or academically be successful in the EMT Program activities?

Yes

Are you covered by personal medical insurance?

Yes

By checking the box below, I understand that it is my responsibility to have adequate insurance to cover any medical treatment that I may encounter during the course of this program.

Have you ever been convicted of a crime other than minor traffic violations?
(Note: DWI is not a minor traffic violation)

Yes

Have you ever applied to or have you ever been a student in any EMT program or are you associated with any volunteer department?

Yes

Applicant Statement

I hereby affirm and declare that all information submitted on this form is true and correct. I understand that false statements or information on this application may be sufficient cause for dismissal from the program. Furthermore, it may be grounds for denial or loss of certification.

Applicant First Name:

Applicant Last Name:

Date

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