ABC RESOURCES EMS PROGRAMS ADMISSION FORM

Date of application______Type of Course: ECA EMT EMT-COM Instructor

Name(Last) (First) (MI)

Address: City _____ Zip______

SSN#: Phone(H) (W)

E-mail address:

Emergency Contact person and phone #:

Employer and phone #: DOB

Please circle your last completed year of education. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 BA MA Ph.D.

Has applicant attended a TDH EMS School previously? YES NO If yes, give class type, date, and location.:

Has applicant had any other medical training or experience? YES NO

If yes, explain

How did you learn about ABC Resources? Newspaper Flyer Friend Phonebook Other

Before class starts, we will need a copy of the following :

High school diploma, transcript, or GED Drivers License Birth Certificate Previous EMS Certification

EACH STUDENT MUST PROVIDE DOCUMENTATION OF TB TINE TEST WITHIN LAST 12MONTHS

Does applicant have any medical conditions that could effect his/her attendance or performance in this class?

YES NO If yes, explain

IT IS STRONGLY RECOMMENDED THAT EACH STUDENT HAVE, OR HAS BEGUN THE HEPTAVAC IMMUNIZATION SERIES PRIOR TO CLINICAL INTERNSHIPS.

I certify that the information in and attached to this application is complete and correct to the best of my knowledge and belief, and that submission of any false information is grounds for rejection of my application, withdrawal of any offer of acceptance, or dismissal after enrollment.

Signature of applicant Date