Paramedic Program Application

Date:
Didactic will be February 26, 2018 – July 2018 (Monday, Wednesday, and Friday)

Time:
8 a.m. – 5 p.m.

After submitting your application you will be emailed instructions on how to upload and send the below required documents. Please make sure to only upload documents in a PDF format. One PDF scan that has all required documents is fine too. If you upload multiple PDFs, please name each PDF with what the document is.

Please note: * (asterisk) Indicates a required field.

Personal Information

First Name

Last Name

Address 1

Address 2

City

State

Zip

Cell Phone

Alternate Phone

Gender

Age

Ethnicity origin and or Race

General Information

Enter date format (mm/dd/yyyy)

Will you be using VA benefits to pay for tuition?

Have you ever been convicted of a felony?

Do you have a current drivers license?

Education History

School Name

Year of Graduation

Have you completed an EMT Basic Course?

School Name

Enter date format (mm/dd/yyyy)

Completion Date

Have you previously attended another Paramedic Program?

School Name

Start Date
Enter date format (mm/dd/yyyy)

End Date
Enter date format (mm/dd/yyyy)

Have you ever been dismissed from a Paramedic Program for academic or behavior issues?

Brief description of the circumstances surrounding the dismissal and what changes you have made in order to be successful in the future.

(100 characters left)

Do you have a Degree?

Type of Degree

Have you completed any college level coursework?

EMT License Information

Registry Number(Format: EXXXXXX)

Certification Expiration (mm/dd/yyyy)

Employment History

Employer: EMT Experience Add More

Please add employers where you gained your EMT experience.

Employer

Name

Part-time / Full-time

Start Date
(mm/dd/yyyy)

End Date
(mm/dd/yyyy)

Full Address

(150 characters left)

Phone Number

Please add up the total amount of time you spent in this position in years/months

Agreements

The $30 application fee is non-refundable

I certify under penalty of perjury that I have provided complete and accurate responses to the items listed on this application.

Payment

Enter your payment information.

$

Credit Type

Expiration Date (mm/yy)

Privacy Policy:

The College of Continuing Education respects your right to privacy. Any information given to us when requesting course or program material will be used solely for the purpose of answering or responding to your request. We do not sell or otherwise distribute your personal information. We may, however, use it to provide you with advanced notices of our course offerings. If at any time you wish to be removed from our mailing lists, you may contact us and your request will be processed immediately.

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