EMS Registration Assistance

EMS Registration Assistance

Please fill out the application form carefully. Any area with an * next to it is a mandatory field.
Personal Information
Full Name (legal name used to enroll as a CAC student)*

First NameLast Name
Personal E-mail*
example@gmail.com
College E-mail (example@stu.centralaz.edu)*
Phone Number*
Please enter your student ID number (starting with 880)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I wish to enroll for the ______________ semester.*

FallSpringSummer
I wish to enroll for the year of ________.*

202420252026Other
Please type the section course (e.g. 23FA00XX) number you wish to enroll into :*
Please type the section code (e.g. EMS1XX) for the course :*
I understand (all areas must be checked to process your registration):*

It is my responsibility to complete the add/drop form if I wish to withdraw from the class.Failure to make payment and/or payment arrangements will results in the loss of registration.Based on the class semester: 100% of tuition/fees will be refunded if the official withdrawal is completed prior to the class start. 90% of tuition/fees will be refunded if the official withdrawal is completed during the official add/drop period. There are NO refunds issued for withdrawals completed after the official add/drop period. Short-Term Classes: 100% of tuition/fees will be refunded if the official withdrawal is completed prior to the class start. There are NO refunds for short-term classes after the start of the class.That upon acceptance and enrollment in the program, I am responsible for all tuition costs and fees due to Central Arizona College.To attend (and complete) EMS programs I must be able to pass a background check and drug screen.Pursuant to Arizona Department of Health policy R9-25-302(D)(1)(a) I understand that I am required to verify that I possess a reading proficiency at a 9th-grade reading level as outlined by Central Arizona College. I understand that this is a prerequisite for admission into the program.
Please answer "yes" or "no" to the questions below.

If you answer yes to any of the questions a detailed report must accompany this application.
Has any healthcare related certification or license you have held 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:

Cancelof
I understand that submission of false information is grounds for denial of admission or immediate suspension if enrolled.

As a student of Central Arizona College, I agree to abide by the Student Code of Conduct of the college regarding conduct and other obligations. In addition, I understand that Central Arizona College institutional student business by electronic delivery. This includes, but not limited to admissions, registration and billings, Form 1098-T and direct deposits. You may withdraw your consent of electronic delivery by writing Central Arizona College, Attn: Accounts Receivable, 8470 N. Overfield Road, Coolidge, Arizona.
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. *

Clear
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.
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EMS Registration Assistance

Personal Information

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