Emergency Medical Services Academy Program Admission Application

Check program(s) for which you are applying:

 

You are urged to give careful consideration to each question on this form. It is to your advantage to fill out this form completely and return it promptly to: RC Health Services


Last Name:

First Name:

Middle Name:


Social Security #:

Date of Birth:

Address:


City:

State:

Zip:


Cell Phone:

Home Phone:

Work Phone:


Would you like to be contact by phone?

Yes

No


E-mail address:

 


Person to Notify in Case of Emergency:

Last Name:

First Name:

Relationship:


Home Phone:

Work Phone:


 


List information concerning high school, college and other schools attended:

Date of desired admission to this program:


Institution:

City/State:

Dates(From-To):

Degree Received:


Have you previously made admission to this program?

Yes

No


GED Certification?

Yes

No

High School Diploma?

Yes

No


Have you ever been convicted of a misdemeanor, felony, DUI or DWI or do you have any charges pending?

Yes

No


If yes, please attach a separate page giving a brief description of the incident. Include dates and penalties assessed.

 


I understand that falsifying any records pertinent to this application can lead to ineligibility or immediate dismissal from the program. My signature below attests that the information contained on this application is true and accurate to the best of my knowledge.

I certify that the PRINTED NAME below is my ELECTRONIC SIGNATURE.


Date:

 

Electronic Signature

 


Click here upload a color copy of your photo ID:



Click here to upload a copy of your high school verification or GED Completion. Acceptable documents include: high school diploma, high school transcripts, college transcripts (MUST have high school name and graduation year on them), GED certificate. We cannot accept college diplomas or college transcripts that do not have the high school name and graduation year listed.



Advanced EMT Students Only! Click here to upload a copy of your current NREMT EMT-Basic certification card. You must scan the front and back of the card for it to be accepted.





Return this document, along with payment and a COLOR copy of a Drivers License or other officially issued Color Photo Identification, to RC Health Services at least five work days prior to the beginning date of the course. This document may either be sent electronically, by mail, or delivered personally.