City EMT Cohort 6 Application Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Email Address Question Title * 4. Address (Street Number & Name) Question Title * 5. Address (City, State, & Zip Code0 Question Title * 6. Telephone Number Question Title * 7. Date of Birth Date Date Question Title * 8. Gender Female Male Non-binary Transgender Intersex Prefer not to say Question Title * 9. What is your race/ethnicity? Check all that apply African American/ Black Hispanic/ Latin American Pacific Islander Asian Caucasian Middle Eastern Multiracial other Question Title * 10. What language(s) are you fluent in? English Spanish Japanese Korean French Chinese Arabic Italian other Question Title * 11. Emergency Contact & Relation (Full Name & Contact Number) Question Title * 12. Have you ever been a part of the foster care system? Yes No Question Title * 13. What is your highest level of education? High School diploma/ GED Some College Associate's Degree Bachelor's Degree Master's Degree Other Question Title * 14. Are you currently enrolled in school? Yes No Question Title * 15. If yes to the previous question, what is the name of the school? Question Title * 16. Are you or would you be the first one in your family to attend college? Yes No Question Title * 17. What is your annual household income? $0-$10,000 $10,000- $30,000 $30,000-$50,000 $50,000- $70,000 $70,000 + Question Title * 18. Do you have a bank account? Yes No Question Title * 19. If you answered no to the previous questions, are you willing to get a bank account? Yes No Question Title * 20. How many people live in your household (including yourself) 1-3 4-5 6+ Question Title * 21. If selected, would you need childcare assistance? Yes No Question Title * 22. Which healthjob/ career do you plan to pursue? (check all that apply) Fire Fighter EMT Paramedic Nurse/ Doctor Medical Technician Pharmacy Radiologist Public Health Unsure Other Question Title * 23. Check all community organizations that you have been involved with. Opportunity for All Young Community Developers Larkin Youth Center Boys and Girls Club Other Question Title * 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) Yes No Question Title * 25. Have you participated in a health career internship program? If yes, please list the name of the program and when you attended. Question Title * 26. Do you currently have a valid drivers license? (Not having your drivers license does not exclude you from participating in the program) Yes No Question Title * 27. If no, are you willing to obtain a valid driver's license by the start of training? Yes No Question Title * 28. Have you previously participated in an EMT course? Yes No Question Title * 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) Yes No Question Title * 30. How did you hear about the City EMT program? Social Media Family/ Friend Community Organization Other Question Title * 31. Why do you want EMT Training and how will it help you to achieve your overall career goal? (Answer in paragraph format) Question Title * 32. Please describe in essay format your personal strengths. Question Title * 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) Question Title * 34. Describe a time you had to act professionally, despite your personal feelings? (Answer in paragraph format) Question Title * 35. Upload Resume PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Upload Resume Question Title * 36. Upload High School Transcripts PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Upload High School Transcripts Question Title * 37. Upload High School Diploma or GED PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Upload High School Diploma or GED Question Title * 38. Upload College transcripts (not Required but if you have them you can send) PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Upload College transcripts (not Required but if you have them you can send) Question Title * 39. Upload Covid Vaccination Card PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Upload Covid Vaccination Card Question Title * 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.Signature & Date Done
