Big Spring EMT Application

EMT PROGRAM APPLICATION

Emergency Medical Technician - Big Spring
Howard College is committed to providing safe and non-discriminatory learning, living, and work environments for all members of the College community. In accordance with applicable federal and state law, the College prohibits discrimination, including harassment, on the basis of race, color, national or ethnic origin, religion, sex, pregnancy, disability, age, sexual orientation, veteran status, or any other legally protected characteristic in employment, educational programs, and admissions.
PERSONAL INFORMATION
Name

First NameLast Name
First Name*
Last Name*
Middle Name
Maiden or Previous Name
Birth Date*

MonthDayYear
Date
Birth Place
City and State
Social Security*
Home Phone
Work
Cell*
Email*
example@example.com
Street Address*
Example: 123 Main St. Apt. #100
City, state, zip*
City*
State*
ZIP*
Permanent Address (If different from local address)

Program Information

Contact office for advance placement options.
Which program are you applying for?*

EMS - BasicParamedic
College Classification*

Classification Freshman (0-29 hours)Classification Sophomore (30-59 hours)Classification Unclassified (60 + hours)
Tell us why you want to be an EMT!*

STATISTICAL INFORMATION
MaleFemale
Ethnicity

White, Non-HispanicAmerican IndianBlack, Non-HispanicHispanicAsian, Pacific IslanderOther, Foreign Student

PREVIOUS EDUCATION
Are you a High School Graduate (or have you completed your GED Equivalence)?*

YesNo
Date of Graduation
Name of High School
Location - City, State
Have you attended (or are you currently enrolled at) another college?*

YesNo
If "Yes" please list other colleges attended.
If you have attended other colleges, please upload/attach a copy of your unofficial transcript.
Attach files here

Cancelof

Acceptance Acknowledgement
If I am accepted as a student at Howard College, I will honor all administrative summons and conform to and abide by the letter and spirit of all the rules, regulations, and procedures of Howard College as given in the college catalog and student handbook. I hereby give the right to disclose to appropriate college officials my school records for use in planning my program. I certify the above information is complete and correct. I acknowledge that deliberate omissions or falsifications may subject me to immediate dismissal from the college.
I understand I will be required to submit a criminal background check and drug screen before acceptance into the program.

If I am not accepted into the program I will need to re-submit my application.
DATE*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Program Information