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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Address (Street Number & Name)

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* 5. Address (City, State, & Zip Code0

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* 6. Telephone Number

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* 7. Date of Birth

Date

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* 8. Gender

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* 9. What is your race/ethnicity? Check all that apply

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* 10. What language(s) are you fluent in?

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* 11. Emergency Contact & Relation (Full Name & Contact Number)

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* 12. Have you ever been a part of the foster care system?

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* 13. What is your highest level of education? 

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* 14. Are you currently enrolled in school? 

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* 15. If yes to the previous question, what is the name of the school? 

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* 16. Are you or would you be the first one in your family to attend college?

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* 17. What is your annual household income?

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* 18. Do you have a bank account?

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* 19. If you answered no to the previous questions, are you willing to get a bank account?

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* 20. How many people live in your household (including yourself)

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* 21. If selected, would you need childcare assistance?

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* 22. Which healthjob/ career do you plan to pursue? (check all that apply)

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* 23. Check all community organizations that you have been involved with. 

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* 24. Have you or anyone in your household been impacted by the COVID-19 virus? (i.e., tested positive, been in close contact with someone who tested positive and had to quarantine)

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* 25. Have you participated in a health career internship program? If yes, please list the name of the program and when you attended.

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* 26. Do you currently have a valid drivers license? (Not having your drivers license does not exclude you from participating in the program)

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* 27. If no, are you willing to obtain a valid driver's license by the start of training?

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* 28. Have you previously participated in an EMT course?

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* 29. Do you have any criminal convictions, currently on parole/ probation or awaiting trial? (If so, this does not preclude you from participating in the program, we ask so that we know which supportive services you may need as a participant)

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* 30. How did you hear about the City EMT program?

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* 31. Why do you want EMT Training and how will it help you to achieve your overall career goal? (Answer in paragraph format)

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* 32. Please describe in essay format your personal strengths.

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* 33. The various careers as a First Responder (EMT, Paramedic, Emergency Room Nurse, Firefighter) can be stressful. What do you do to stay calm? (Answer in paragraph format)

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* 34. Describe a time you had to act professionally, despite your personal feelings? (Answer in paragraph format)

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* 35. Upload Resume

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 36. Upload High School Transcripts

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 37. Upload High School Diploma or GED

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 38. Upload College transcripts (not Required but if you have them you can send)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 39. Upload Covid Vaccination Card

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 40. By submitting this application, I affirm that I have answered all questions completely and truthfully. I understand that if I am accepted, any false statements, omissions or other misrepresentations made by me on this application may result in my immediate dismissal. Your application will be considered incomplete until all documents have been received. If you have any questions, please contact admin@cityemt.org.
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