EMT Program Application

Legal Name*

First Name

Last Name

Suffix

FullName

Legal Name

First NameMiddle NameLast NameSuffix

Preferred Name

Email*

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Citizenship*

USNon-US

VISA*

Date of Birth*

Date

Days Old

Today

Date

According to your birthday, you are under 16. Virignia Office of EMS Regulations stipulate that EMT course attendees must be 16 years of age prior to the start date of the coruse.

If you will be 16 on or before the start date of the next EMT completion course, please email Jonathan.Alford@vcuhealth.org for an override code.

If you do not have an override code, STOP. You will not be able to submit your application without an override code.

Override Code*

Code Accepted. You may proceed.

check

According to your birthday, you are under 18. You will need to provide the name and email address of a parent or legal gaurdian. PUT THIS INFORMATION IN THE BOXES BELOW.

They will recieve an email with information about the course and must consent your participation in the course. Your application will not be approved until this is received.

Parent First Name*

Parent Last Name*

Parental Email Address*

example@example.com

Parental Phone Number*

Please enter a valid phone number.

The Center for Trauma and Critical Care Education (CTCCE), periodically, is the recipient of federal grant(s). By answering the following questions, you may help the CTCCE to receive these supplemental funds for our programs, that may or may not have a direct benefit to you and/or your employer.

Answers to questions regarding gender, race, ethnicity, and sexual orientation is optional (select "Choose not to answer"). Your answer does not affect your admission into the program. Your confidential information will be protected.

For more information, please visit https://ctcce.vcu.edu/programs/cara-grant-projects/ or contact Jonathan.Alford@vcuhealth.org

Race*

Are you Hispanic or Latino?*

Gender*

Sexual Orientation*

Send Voucher Application

Employment/Student Status*

School*

Intended Major*

Expected Graduation*

Current GPA*

Pre-Med

I want to take this course for patient contact experience for medical school

Employer*

Appox Hours per week*

Do you volunteer for an EMS agency?*

YesNoApplied

EMS Agency*

Significant Workload - I understand that the EMT course is the equivalent of an 8-hour credit course, and thus, it is not advisable to take a heavy load of courses while taking this course.*

I understand

Have you previously taken an EMT course?*

NoYes - passedYes - did not complete

What year was this EMT Course?*

Where?*

Please read the prerequisites for obtaining EMS Certification in Virginia (TR-35). This is available here: https://www.vdh.virginia.gov/content/uploads/sites/23/2016/05/TR-35-Prereqs-and-Conduct-3-5-19.pdf

I have read the TR-35 form and I meet all prerequisites and requirements.*

NoYes

Resume/CV*

PDF, DOC, or DOCX only

The statement should be 300-500 words explaining why you want to take the EMT course. PDF or Word format, only, please.

The file name should be "Lastname - Personal Statement.docx" (or .pdf)

Include your full name at the top of the document.

Statement*

PDF, DOC, or DOCX only

Don't have a professional headshot?

Here are some tips for taking one yourself:

https://www.indeed.com/career-advice/resumes-cover-letters/how-to-take-your-own-headshot

Professional Headshot*

JPG, PNG only

Signature - All information is true and correct to the best of my ability. *

EMT Program Application

Program

EMT Program Application

EMT Course Requirements and Workload

EMT Course Application

Identity

Employment/Student

Background

Documents