Methodist EMS Academy Course Application

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* 1. Please fill out the below with your information

First, Last Name

Date of Birth

Phone Number

Email address

Drivers License Number

State issuing Drivers License

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* 2. Which course are you applying for?

EMR

EMT

Advanced EMT

Paramedic

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* 3. Are you currently an EMT? You may need to provide a copy of your certification.

Yes

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* 4. Polo Shirt Size

Small

Medium

Large

X-Large

XX-Large

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* 5. Are you 18 or older?

Yes

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* 6. Are you sponsored by a department?

Yes

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* 7. If yes, Which department?

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* 8. Please provide a contact to your department.

First, Last Name

Title

Phone Number

email address

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* 9. Have you ever been convicted of a Felony?

Yes

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* 10. Have you ever been convicted of a Class A misdemeanor?

Yes

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* 11. Have you ever been convicted of a class B misdemeanor?

Yes

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* 12. Are you currently on probation?

Yes

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* 13. Have you ever been convicted of a crime while driving under the influence of drugs or alcohol?

Yes

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

Yes

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* 15. Please provide a copy of professional references.

Name, Title, Phone Number, email address

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* 16. You will be required to sign and return a criminal history disclosure agreement. This information is protected and private and will not be shared with anyone.

Yes, I consent to criminal history disclosure agreement

No, I do not consent to criminal history disclosure agreement