ACADEmy In-Person EMT Application

ACADemy In-Class EMT Enrollment Application

Last Name *

First Name *

Middle Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Cell Phone *

Home Phone

Work Phone

Date Of Birth *

Email Address *

Please indicate your golf shift size (XS, S, M, L, XL, XXL, XXXL): *

Men’s and Women’s sizes are available, please make sure to indicate if you want men’s or women’s sizing.

Have you ever been convicted of a misdemeanor, felony, DUI or DWI or do you have any charges pending? *

Yes

If yes, please attach a separate page giving a brief description of the incident. Include dates and penalties assessed.

How did you hear about the ACADemy In-Class EMT Program *

EMERGENCY CONTACT INFORMATION

Emergency Contact Name *

Emergency Contact Relationship to Student *

Emergency Contact Phone #1 *

Emergency Contact Phone #2

Required Enrollment Documents

Click here upload a color copy of your photo ID: *

Maximum file size: 20.97MB

Birth Certificate/Proof of Residency: *

Maximum file size: 20.97MB

Click here to upload a copy of your high school verification or GED Completion: *

Maximum file size: 20.97MB

Acceptable documents include: high school diploma, high school transcripts, college transcripts (MUST have high school name and graduation year on them), GED certificate. We cannot accept college diplomas or college transcripts that do not have the high school name and graduation year listed

Proof of Payment

Maximum file size: 20.97MB

Please go to https://www.patientnotebook.com/adaircountyambulancedistrict/payment to complete your online payment and pay in full or make the initial 3 part payment. Please Save your receipt and attach it here for proof of payment.

reCAPTCHA

I understand that falsifying any records pertinent to this application can lead to ineligibility or immediate dismissal from the program. My signature below attests that the information contained on this application is true and accurate to the best of my knowledge. I also understand that I will have access to a digital copy of the textbook, but will not receive a “physical” text. If I would like to purchase one I can use the below link to do so:

http://www.jblearning.com/cart/Default.aspx?bc=08017-9&ref=psg&coupon=PSGQ119

Date

Electronic Signature

I certify that the PRINTED NAME below is my ELECTRONIC SIGNATURE.

If you are human, leave this field blank.

ACADEmy In-Person EMT Application

EMERGENCY CONTACT INFORMATION

Required Enrollment Documents

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