<p> ABC RESOURCES EMS PROGRAMS ADMISSION FORM</p><p>Date of application______Type of Course: ECA EMT EMT-COM Instructor</p><p>Name(Last) (First) (MI) </p><p>Address: City _____ Zip______</p><p>SSN#: Phone(H) (W) </p><p>E-mail address: </p><p>Emergency Contact person and phone #: </p><p>Employer and phone #: DOB </p><p>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.</p><p>Has applicant attended a TDH EMS School previously? YES NO If yes, give class type, date, and location.:</p><p>Has applicant had any other medical training or experience? YES NO </p><p>If yes, explain </p><p>How did you learn about ABC Resources? Newspaper Flyer Friend Phonebook Other</p><p>Before class starts, we will need a copy of the following :</p><p>High school diploma, transcript, or GED Drivers License Birth Certificate Previous EMS Certification</p><p>EACH STUDENT MUST PROVIDE DOCUMENTATION OF TB TINE TEST WITHIN LAST 12MONTHS </p><p>Does applicant have any medical conditions that could effect his/her attendance or performance in this class? </p><p>YES NO If yes, explain </p><p>IT IS STRONGLY RECOMMENDED THAT EACH STUDENT HAVE, OR HAS BEGUN THE HEPTAVAC IMMUNIZATION SERIES PRIOR TO CLINICAL INTERNSHIPS. </p><p>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. </p><p>Signature of applicant Date</p>