GA EMS Leadership Program Application

GA EMS Leadership Program Application 2025

Deadline to submit: January 31, 2025 at 5 pm
With funding support from the Georgia Trauma Care Network Commission, the Georgia EMS Association (GEMSA) is pleased to announce the 14th year of the Emergency Medical Services (EMS) Leadership Education and Training Program for 2025. GEMSA is now accepting applications from EMS service providers in Georgia.

Below are the elements of application for this course. To be considered, your
application MUST contain the following documents:
1. Minimum Qualifications – A, B or C
2. Letter of Endorsement – A, or B, or C
3. Student Information
4. Student Essay
5. Student Commitment Verification & 6. Supervisor acknowledgement of Leadership participation (link below)

Download the commitment verification form here (requires signatures).

Details regarding each element are provided on the form below. You are required to upload supporting documents.

All application materials must be submitted to GEMSA by January 31, 2025 at 5 pm.
Applicant Name*

First NameLast Name
Have you applied for the leadership program previously?*

YesNo
If yes, when?
1. Minimum Qualifications
Please upload documentation stating that you are:
- A - EMS Director or
- B - Deputy Director (requires endorsement from Director) or
- C – Supervisory/Management level primary job responsibility (requires endorsementfrom Director/ Supervisor)
Qualification Letter Upload*

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2. Letter of Endorsement
Please upload a letter of endorsement from one of the following depending on your service type:
- A - Commission Chair or County Manager/Administrator, if county-based; or
- B - CEO, if hospital-based; or
- C - Corporate CEO, if private
Letter of Endorsement Upload*

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3. Applicant - Service Contact Information
Service/Organization name*
Job Title*
Supervisor
Service Director*
Type of Service

PublicPrivateOther
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
Please enter a valid phone number.
Work Email*
example@example.com
Applicant - Personal Contact Information
Preferred Name (if different from above)

First NameLast Name
Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Cell Phone Number*
Please enter a valid phone number.
Personal Email*
example@example.com

Training and Background - (Upload additional pages if necessary)
Current Certifications
Highest Degree Earned
How many years have you worked in EMS?
If applicable, how many years have you worked in rural EMS?
How many years have you worked in your current position?
How many years of supervisory experience do you have?
Do you work for more than one service? If so, please list other service.
Briefly describe your job duties, or attach a copy of your current job description:
Job Description File or Other Documentation (Upload Here)

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Student Essay
Please write a Statement of Interest, not to exceed one page. This essay should
detail why you are seeking leadership training. Upload the file below.
Student Essay Upload*

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Student Commitment Verification & Supervisor Acknowledgement
Download the commitment verification form here.

Print the form, read it carefully, sign it, have your supervisor sign it, then scan or take a photo of it and upload it below.
Student Commitment Verification & Supervisor Acknowledgement Document Upload*

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All application materials must be submitted to GEMSA no later than January 31, 2025 at 5 pm using this form.

If you have questions or issues with the online form, send an email to Kim Littleton, Leadership Program Director - director@georgiaemsassociation.com.
Should be Empty:

GA EMS Leadership Program Application 2025

1. Minimum Qualifications

2. Letter of Endorsement

3. Applicant - Service Contact Information

Applicant - Personal Contact Information

Training and Background - (Upload additional pages if necessary)

Student Essay

Student Commitment Verification & Supervisor Acknowledgement