Application for Course Enrollment
Select Level of Course:
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Please Select
EMT
Advanced EMT
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone #
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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example@example.com
Social Security #
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Date of Birth
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/
Month
/
Day
Year
Date
Do you have a high school diploma or GED?
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Please Select
Yes
No
Do you have a current American Heart Association BLS Provider Certification?
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Please Select
Yes
No
Do you have a current American Heart Association BLS Provider Certification?
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Please Select
Yes
No
For any and all criminal offense(s) or conduct, including those pending an appeal, have you ever: (select any that apply)
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been convicted of a misdemeanor?
been convicted of a felony?
received deferred adjudication?
received pre-trial diversion?
received deferred disposition?
been placed on community supervision or court-ordered probation?
been sentenced to serve jail or prison time or court-ordered confinement?
been arrested?
been criminally charged or have any pending criminal charges?
been subject of a court martial or received any form of other military judgement, punishment, or action?
been or currently the target of a grand jury or governmental agency investigation?
had any licensing/certification authority refuse to issue you a license or certification?
had any licensing/certification authority revoke, annul, cancel, suspend, place on probation, refuse to renew, or accept a surrender of a license or certificate held by you for criminal conduct?
had any licensing/certification authority fine, censure, reprimand, or otherwise discipline you for criminal conduct?
used any illicit or illegal drugs, abused prescription medication, or had any other drug/substance abuse issues in the past twelve (12) months?
None of the these apply
For each item above to which you selected, provide a detailed written explanation. the explanation must include the name of the criminal charge and offense, date of the charge, offense case #, description of sentence, punishment or disciplinary action, and location (city/county/state) where the offense occurred.
If accepted into the program, what size polo-style shirt would you need?
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Please Select
Small
Medium
Large
X-Large
2X-Large
3X-Large
4X-Large
Our EMS education program utilizes many different online resources for curriculum, assignments, testing, etc. Do you have a reliable tablet/laptop/PC and internet access that can be used for this course?
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Please Select
Yes
No
Please give a brief explanation of why you are seeking to further your EMS education with our education program.
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Have you read, and do you understand all of the requirements listed throughout the contained program policies and application packet?
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Please Select
Yes
No
If affiliated with a volunteer fire department, please enter VFD name here.
If accepted into the course, please select method of payment:
*
Please Select
PAY IN FULL - Credit/Debit
PAY IN FULL - ACH
Invoice to My Department
Payment Plan Requested
I attest, by my signature below, that the facts set forth in this student application are true and correct to the best of my knowledge. I understand that if I am accepted into the education program any false statements made on this application shall be considered sufficient cause for dismissal from the education program without any type of refund. I authorize Taylor County EMS Education Program to make any investigations of the information I attest to in this application.
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Submit
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