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Methodist EMS Academy Course Application
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1.
Please fill out the below with your information
(Required.)
First, Last Name
Date of Birth
Phone Number
Email address
Drivers License Number
State issuing Drivers License
*
2.
Which course are you applying for?
(Required.)
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.
(Required.)
Yes
No
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4.
Polo Shirt Size
(Required.)
Small
Medium
Large
X-Large
XX-Large
3x
4x
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5.
Are you 18 or older?
(Required.)
Yes
No
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6.
Are you sponsored by a department?
(Required.)
Yes
No
*
7.
If yes, Which department?
(Required.)
*
8.
Please provide a contact to your department.
(Required.)
First, Last Name
Title
Phone Number
email address
*
9.
Have you ever been convicted of a Felony?
(Required.)
Yes
No
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10.
Have you ever been convicted of a Class A misdemeanor?
(Required.)
Yes
No
*
11.
Have you ever been convicted of a class B misdemeanor?
(Required.)
Yes
No
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12.
Are you currently on probation?
(Required.)
Yes
No
*
13.
Have you ever been convicted of a crime while driving under the influence of drugs or alcohol?
(Required.)
Yes
No
*
14.
Do you have a high school diploma or GED?
(Required.)
Yes
No
*
15.
Please provide a copy of professional references.
(Required.)
Name, Title, Phone Number, email address
Name, Title, Phone Number, email address
*
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.
(Required.)
Yes, I consent to criminal history disclosure agreement
No, I do not consent to criminal history disclosure agreement
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