Application for Paramedic 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.

EMT Program/School name*

State the EMT program is located:

Entry date

Date

Graduation date*

Date

State and Certification number*

State Expiration Date*

Level*

Years Certified*

National Registry Number (if applicable)

National Registry Expiration Date

List any other states than the one listed above that you hold EMT certification in:

College

Credits earned

Did you graduate

YesNo

Degree Received

Field of study

College

Credits earned

Did you graduate

YesNo

Degree Received

Field of study

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)*

	0	1 (C)	2 (B)	3 (A)	Summary
ENG101 or Higher
MAT118 or Higher
BIO160 or Higher: Must have been completed in the last 3 years
EMT Course

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.

Please upload your DD214 here.

Employer

Start date with employer

Date

Supervisors Name

Phone Number

Will your employer be offering you any scholorships or funding while you are in the program?

YesNo

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

File Upload

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

File Upload

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

File Upload

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

Has your certification or license ever 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 paramedicine 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.

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

I understand that entrance and completion of the paramedic program does not guarantee paramedic 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

Interview Date

Date

Interview results

Pretest score

>9080-89.970-79.969.9<

Paramedicine Program Application

Personal Information

EMS Educational Background

EMT Certification

College Credits or Degrees

Military Service

Present Employer

Letters of recommendation:

EMT and CPR Cards:

Hazardous Materials Certificate

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