GMR Scholarship Application for the EMT Program

Full Name*

First NameLast Name

E-mail*

example@example.com

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I certify I am (check all that apply):*

a Pinal county resident:employed with an emergency agency serving Pinal countynone of the above

If you work for a municipal agency serving Pinal County please upload a document verifying employment (e.g. a letter from a supervisor with your agencies letterhead):

Please upload files in the following formats pdf, jpeg, png, jpg, doc, or docx.

Profession

(e.g. RN, LPN, Pharm Tech, CNA)

State and Certification/License number

(if you do not have a license number put N/A)

Expiration date

(if you do not have expiration put N/A)

Years Certified

I understand to receive Scholarship funding I must be able to provide proof of one of the following: Completion of ENG101 (from a state-credentialed college), SAT Evidence-Based Reading and Writing score of 480 or greater, ACT score of 22 or greater in reading, or a score of 80% or more on the Reading Comprehension section of the HESI exam.

YesNo

College #1 (or Technical School)

Credits earned

Did you graduate

YesNo

Graduation Date

Degree Received

Field of study

College #2 (or Technical School)

Credits earned

Did you graduate

YesNo

Degree Received

Field of study

Graduation Date

Other Colleges or Technical programs

Upload unofficial transcripts here

Please upload files in the following formats pdf, jpeg, png, jpg, doc, or docx.

Highest degree earned

Application Academic points (Please check off the grade you received 1 = C, 2=B, and 3=A). Students that have completed a college level English course and a human anatomy course will be give additional consideration for the scholarship.*

	n/a	1 (C)	2 (B)	3 (A)	Course number
ENG101 or Higher
MAT118 or Higher
Human Anatomy - Must have been completed in the last 3 years
Medical Terminology

Your academic score is totaled here:

I have served (or am currently serving) in the United States :

By selecting one of the above you are stating that you have either been honorably discharged or are stlil on active duty status.

Current Military Status

Please upload your DD214 here.

Employer

Start date with employer

Date

Supervisors Name

Phone Number

Please list any other patient care, volunteer service, or EMS work history (e.g. organization, position, length of employment, etc.)

Points awarded for EMS or Volunteer Service

File Upload

Please upload files in the following formats pdf, jpeg, png, jpg, doc, or docx.

Have you ever had and medical certification or license that has been been refused, suspended, or revoked?*

YesNo

Have you ever been convicted drug related offence and or treated for any drug addiction?*

YesNo

Have you ever been convicted of a felony or any crime listed in the National Registry of EMT's criminal conviction policy? Go to https://www.nremt.org/Policies/Certification-Policies/Criminal-Conviction for more information.*

YesNo

You will need to complete a criminal background check and pass a 10-panel drug screen to attend clinical rotations and field internships. Is there any reason you will not pass both of these checks?*

YesNo

If you answer "yes" to any of the four questions above place supporting documentation here:

I fully understand that any significant misstatement in or omission from this application constitutes cause for dismissal from the Emergency Medical Technician (EMT) program. All information submitted by me in this application is true to the best of my knowledge.

I hereby further authorize and consent to the release of any information by this college, hospitals, or other departments as appropriate regarding information relevant to the training program as long as the release of that information is done in good faith and without malice, and I hereby release from liability Central Arizona College and its representatives for doing so.

I understand that Central Arizona College and its clinical/vehicular sites acknowledge that certain information pertaining to the condition and care of patients is confidential and, unless waived by the patient, is entitled to protection from disclosure under the law.

I understand I must be able to comply with the requirements of the clinical/vehicular sites that participate in Central Arizona College EMS programs. This includes all standards regulated by federal law that pertain to vaccination status, physical job requirements, and screening policies

I understand that upon acceptance and enrollment in the program, I am responsible for all tuition costs and fees due to Central Arizona College that may not be covered by the scholarship

I understand that submission of this application is the first step in the process and does not guarantee compensation for the program.

I understand that entrance and completion of the EMT program does not guarantee state or national registry certification.

I understand that acceptance into the program is contingent on meeting standards the background check and having clean drug screen results.

I have completed this application truthfully and to the best of my ability. I understand and agree to the program requirements listed in the application. *

Central Arizona College provides equal opportunity in employment, educational programs, and activities. Discrimination is prohibited on the basis of race, color, religion, sex, age, disability, national origin, military status, sexual orientation, or any other classification protected by federal and state law.

Calculation

Emergency Medical Technician Scholarship Application (sponsored by the GMR foundation)

Personal Information

Do you hold and current medical certification or licenses?

Proof of reading comprehension at a 10th-grade level as required by the Arizona Department of Health Services.

Educational Background: College Credits or Degrees

Military Service

Present Employer

Letters of recommendation:

Please answer "yes" or "no" to the questions below.