EMT Program Application

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* 1. Applicant Information

First Name

Middle Initial

Last Name

Street Address

City

State

Zip Code

Cell Phone Number

Last 4 Digits of SSN

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* 2. Which EMT course are you applying for?

Feb 7 - Apr 30; Stoughton campus

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* 3. Email Contact

Email Address

Secondary Email Address

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* 4. Emergency Contact Information

Name

Relationship

Phone Number

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* 5. Do you have a high school diploma or GED?

Yes

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* 6. Advanced Education

College or Univeristy

Year of graduation or predicted graduation date

Are of study

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* 7. Please use the space below to answer the following question:
Why would you be a great candidate for our EMT Program?

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* 8. What would be your largest challenge in completing an EMT Program?

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* 9. Please indicate YES to the following statements as confirmation of understanding.

	Yes	No
I understand that this program requires me to act professionally at all times.	I understand that this program requires me to act professionally at all times. Yes	I understand that this program requires me to act professionally at all times. No
I understand that I am responsible to pay a non-refundable deposit	I understand that I am responsible to pay a non-refundable deposit Yes	I understand that I am responsible to pay a non-refundable deposit No
I understand that this program requires me to be subject to criminal and / or background checks, the results of which may affect my admission and / or continued participation in this program.	I understand that this program requires me to be subject to criminal and / or background checks, the results of which may affect my admission and / or continued participation in this program. Yes	I understand that this program requires me to be subject to criminal and / or background checks, the results of which may affect my admission and / or continued participation in this program. No
I understand that this program prepares me for licensing and / or credentialing as an EMT, but it neither licenses or certifies me as an EMT.	I understand that this program prepares me for licensing and / or credentialing as an EMT, but it neither licenses or certifies me as an EMT. Yes	I understand that this program prepares me for licensing and / or credentialing as an EMT, but it neither licenses or certifies me as an EMT. No
I understand that my tuition does not include NREMT exam fees.	I understand that my tuition does not include NREMT exam fees. Yes	I understand that my tuition does not include NREMT exam fees. No
I agree to pay, in full, all tuition and exam fees according to the policies set forth by First Response EME	I agree to pay, in full, all tuition and exam fees according to the policies set forth by First Response EME Yes	I agree to pay, in full, all tuition and exam fees according to the policies set forth by First Response EME No

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* 10. You will receive an email confirmation once we process your application

First Response Emergency Medical Education does not discriminate on the basis of race, creed, color, sex, age, nationality, or sexual orientation.

I hereby attest and affirm that I am committed to this EMT program and will make sufficient time available for its completion. I also attest to the fact that all information provided by me is true and correct to the best of my knowledge. Any attempt to offer incorrect or fraudulent information will result in immediate withdrawal of this application, termination from the program, and forfeiture of future program acceptance.

Name

Electronic Signature

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100% of survey complete.

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* 1. Applicant Information

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* 2. Which EMT course are you applying for?

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* 3. Email Contact

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* 4. Emergency Contact Information

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* 5. Do you have a high school diploma or GED?

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* 6. Advanced Education

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* 7. Please use the space below to answer the following question: Why would you be a great candidate for our EMT Program?

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* 8. What would be your largest challenge in completing an EMT Program?

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* 9. Please indicate YES to the following statements as confirmation of understanding.

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* 7. Please use the space below to answer the following question:
Why would you be a great candidate for our EMT Program?