EMS EMT Application

SummerFall
Your Name:*

First NameLast Name
NSHE ID (Student ID Number):*
Email:*
example@mail.tmcc.edu
Phone Number:*
Please enter a valid phone number.Format: 000-000-0000.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
YesNo
YesNo
Name of medical insurance?
Date of Your Background Check Submission:*

MonthDayYear
Date of Your Drug Test Submission:*

MonthDayYear
Identification
Driver's License/ID State:*
Driver's License or State ID Number:*
Driver's License/State ID Expiration Date:*

MonthDayYear
Expiration Date of AHA BLS CPR card?*

MonthDayYear
Hepatitis B Series (3 doses) or Titer

The hepatitis B vaccine is a series of 3 shots. You need two by the start of class.
Vaccine Date (3 doses)Titer Drawn Date (proof of immunity)
Dose 1 Date:*

MonthDayYear
Dose 2 Date:*

MonthDayYear
Dose 3 Date:

MonthDayYear
Titer Drawn Date:*

MonthDayYear
MMR Series (2 doses) or Titer

MMR vaccine is a series of two shots.
Vaccine Date(2 doses)Titer Drawn Date (proof of immunity)
Dose 1 Date:*

MonthDayYear
Dose 2 Date:

MonthDayYear
Titer Drawn Date:*

MonthDayYear
Varicella Immunity, Titer, or Verified History of Chickenpox
Vaccine Date (2 doses)Titer Drawn Date (proof of immunity)Verified History of Chickenpox
Dose 1 Date:*

MonthDayYear
Dose 2 Date:*

MonthDayYear
Titer Drawn Date:*

MonthDayYear
Date of Diagnosis or Clinical History:*

MonthDayYear
Tuberculosis (TB), QuantiFERON or Chest X-ray

TB vaccine is a series of two shots. QuantiFERON must be within the last year. Chest x-ray should be within the last 5 years.
Vaccine Date (2 doses)QuantiFERON DateChest X-ray Date
Dose 1 Date:*

MonthDayYear
Dose 2 Date:*

MonthDayYear
QuantiFERON Date:*

MonthDayYear
Chest X-ray Date:*

MonthDayYear
FLU
I will provide vaccine date (must be within one year)N/A - I will submit a declination form due to medical/religious reasons
Flu Vaccine Date:*

MonthDayYear
COVID-19
I will provide vaccine date (must be within one year)N/A - I will submit a declination form due to medical/religious reasons
COVID-19 Vaccine Date:*

MonthDayYear
Other
Date of Tetanus, Diphtheria, and Pertussis vaccine?*

MonthDayYear
What is your t-shirt size?*
Certification and Acknowledgment

By pressing submit, I certify that all of the information provided above is true, correct and complete. Additionally, I understand that this degree/certificate leads to professional licensure in Nevada. Licensing requirements vary by state and territory, and relocating may impact my eligibility for licensure. If I do not reside in Nevada and/or do not plan to seek employment in Nevada, my application will be reviewed to determine eligibility for licensure in my state before acceptance into the program.
Please verify that you are human:*
Sender Name:
Should be Empty:

Identification

Hepatitis B Series (3 doses) or Titer

MMR Series (2 doses) or Titer

Varicella Immunity, Titer, or Verified History of Chickenpox

Tuberculosis (TB), QuantiFERON or Chest X-ray

FLU

COVID-19

Other

Certification and Acknowledgment