Student Application
EMT Course
After submission of this application, you will receive an email from jbdclanham@gmail.com or brittany.lanham@mcleancountyky.gov This email will contain an invite to our Teams Channel, precourse materials and instructions. All payments-tuition and materials are required by the course start date
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Select any of the following that you hold:
Please Select
CPR
EMR
High School Diploma/GED
If you have not graduated high school, when is your expected graduation date?
I understand that if I need CPR certification, that will be an additional $20.00 due at the first class. AHA BLS PROVIDER is required. Please select if you need this certification
*
Please Select
Yes, I need BLS PROVIDER
No, I hold this certificate and it is within date
I understand that I need to complete and provide course completion certificates for the free KBEMS required courses: Pediatric Abuse Head Trauma, HIV/AIDS for EMS Providers, Awareness of Sexual Violence Training
*
Please Select
Yes
https://kbems.ky.gov/Education/Pages/default.aspx
I understand that I need to complete and submit a background check for KBEMS through Viewpoint
*
Please Select
Yes
https://kbems.ky.gov/Certification-And-Licensure/Documents/KY%20Board%20of%20EMS%20-%20Viewpoint%20Screening%20BG%20Check%20Instructions.pdf
Summarize special skills and qualifications you have acquired from experience, previous volunteer work or through other activities, including hobbies or sports
*
Please Provide an Emergency Contact Name and Phone Number
*
Please upload a copy of your driver's license
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You will need to provide a copy of your social security card. You may email it, or bring it on or before the 1st class
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