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Nonrefundable Application

**PLEASE NOTE THAT THE APPLICATION FEE DOES NOT SECURE YOUR SEAT IN THE CLASS!! ONLY THE FULL TUITION PAYMENT OR DEPOSIT PAYMENT WILL SECURE YOUR SEAT!! YOU CAN MAKE THIS PAYMENT AT YOUR ADMISSIONS APPOINTMENT WHICH YOU CAN BOOK ONCE THE APPLICATION IS COMPLETED AND SUBMITTED!!**
Enrollment Status*
Application*
Applicant Name*

First NameMiddle NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Email Address*
example@example.com
Gender*
Date of Birth*

MonthDayYear
Date
Last four digits of Social Security Number*
Ethnicity

AsianBlack/African descentEast IndianLatino/HispanicMiddle EasternNative AmericanPacific IslanderWhite/Caucasian (non-Hispanic)Other
Level of Education Completed*

General Education DiplomaHigh School DiplomaSome CollegeTwo Year DegreeFour Year Degree
Citizenship*

U.S. CitizenPermanent ResidentStudent VisaOther
Have you Ever Been Convicted of a Felony?*

YesNo
If yes, Please Explain*
Student Program Objective*

Job RelatedPersonal Enrichment
If job related, where do you currently work*
Date of Hire*
Supervisors Name*
Phone Number*
Please enter a valid phone number.
Have You Ever Attended EMT School Before?*

YesNo
Have You Ever Attended Paramedic School Before?*

YesNo
If yes, where did you attend?*
What Year?*
Have you ever attended Fire School?*

YesNo
Certificate obtained?*
If yes, where did you attend?*
What Year?*
Do you work for a(n) EMS or Fire Department?*

YesNo
If yes, what department?*
Month/Year of hire*
EMT Certified*

YesNo
If yes, EMT license expiration date*
Are you younger than 18 years of age?*

YesNo
Signature*

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If under 18 years of age, a Parent/Guardian Electronic Signature is REQUIRED.
Select Course
Application Fee

Pay Application Fee

Application Fee*

Pay Application Fees

$150.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

7741 N. Military Trail, Suite 4/5, Palm Beach Gardens, FL 33410

PH: (561) 283-0400

FX: (561) 229-1066
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Nonrefundable Application

Application Fee