MCAD EMT Student Application

Monroe City Ambulance District

EMT Student Application
Applicant Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security Number
Are you a citizen of the United States?
Have you ever been convicted of a felony?
If you answered "Yes" to the previous question, please explain.
Please put N/A if you answered "No" to the previous question

Emergency Contact
Emergency Contact #1

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you
Mother, father, spouse, friend, etc
Emergency Contact #2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you
Mother, father, spouse, friend, etc.
Education
High School:
Name of High School attended
Years Attended
ex: 2010-2014
Did you graduate?
College:
Name of college attended
Years Attended
ex: 2010-2014
Did you graduate?
If yes, what degree/certification was obtained?
Please put N/A if no degree/certification received
Other Education:
Name of other educational institution attended
Years Attended
ex: 2010-2014
Did you graduate?
If yes, what degree/certification was obtained?
Please put N/A if no degree/certification received

Employment

Please provide at least 2 years of employment history
Company
Supervisor Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Years Employed
Ex: 2010-2015 or "Current" if still currently employed
May we contact this employer for a reference?
Company
Supervisor Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Years Employed
Ex: 2010-2015 or "Current" if still currently employed
May we contact this employer for a reference?
Company
Supervisor Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Years Employed
Ex: 2010-2015 or "Current" if still currently employed
May we contact this employer for a reference?

References

Please list at least 3 non-relative, professional references.
Reference #1

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you
Teacher, co-worker, friend, etc.
Reference #2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you
Teacher, co-worker, friend, etc.
Reference #3

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you
Teacher, co-worker, friend, etc.

Notice to students
1. Do not sign this agreement before you have read it or if it contains any blank spaces.
2. This agreement is a legally binding instrument and is only binding when the agreement is accepted, signed, and dated by the authorized official of the Monroe City Ambulance District Training Center. Read all pages of this contract before signing.
3. You are entitled to an exact copy of the agreement and any disclosure pages you sign.
4. Any changes in this agreement must be made in writing and shall not be binding on either the student or the Training Center unless such changes have been approved, in writing, by the authorized official, Program Director of the Training Center, and by the student or the student's parent or legal guardian. All terms and conditions of the agreement are not subject to amendment or modification by oral agreement.
5. The Training Center does not guarantee the transferability of credits to another Training Center, college, or university. Credits or coursework are not likely to transfer. Any decision on the comparability, appropriateness, and applicability of credit and whether credit should be accepted is the decision of the receiving institution.
Student Acknowledgements
1. Student Initials*I certify that I am at least 18 years of age or I have attached the required and signed parent/guardian consent forms.
2. Student Initials*I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application may result in my release from the program without refund.
3. Student Initials*I understand that the Training Center may terminate my enrollment if I fail to comply with attendance, academic, or financial requirements or if I fail to abide by established standards of conduct.
4. Student Initials*While enrolled in the Training Center, I understand that I must maintain satisfactory academic progress and that my financial obligation to the Training Center must be paid in full before a certificate of credential may be awarded.
5. Student Initials*I hereby acknowledge that the Training Center Program Director has made available to me all disclosure information as required by law.
6. Student Initials* I understand that the Training Center does not guarantee transferability of credit and that in most cases, credits or coursework are not likely to transfer to another institution. In cases where transferability is guaranteed, Monroe City Ambulance District Education Department must provide me copies of transfer agreements that name the exact institution(s) and include agreement details and limitations
7. Student Initials*I understand that the Training Center does not guarantee job placement to graduates upon program completion.
8. Student Initials* I understand that complaints, which cannot be resolved by direct negotiation with the Program Director in accordance to its written grievance policy, may be filed with the Monroe City Ambulance District Administration, 225 Fifth St., Monroe City, MO 63456
By signing this contract, the student acknowledges that he/she has read this contract, understands the terms and conditions, and agrees to the conditions outlined in this contract. It is further understood that this agreement supersedes all prior or contemporaneous verbal or written agreements and may not be modified without written agreement of the student and the Program Director. The Training Center will retain a copy of this agreement.
Signature
Should be Empty:

Monroe City Ambulance District

Applicant Information

Emergency Contact

Education

Employment

References

Notice to students

Student Acknowledgements