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Printable Paramedic (MICT) Program Application

Paramedic (MICT) Program Application in Word format.

PERSONAL INFORMATION:

Name: _____________________________________________________

Date: ________________________

Address:______________________________________________

SSN: ______________________________

City: __________________________________

State: ___________________

Zip Code: _________________

Home Phone: ______________________________________

Cell Phone: ________________________________________

E-mail: __________________________________


EDUCATIONAL BACKGROUND:

High School: ________________________________________________

Year Graduated: _______________

College: ____________________________________________________

Hours Completed: ______________

Degree: _______________

Year Graduated: __________________

Other Education/Training (describe): ____________________________________________________

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PROGRAM PREREQUISITES:

Are you currently a certified EMT? _____ Yes _____ No

Have you completed the anatomy & physiology class? _____ Yes _____ No Grade__________

Have you completed the English Composition class? _____ Yes _____ No Grade__________

Have you completed the computer class? _____ Yes _____ No Grade__________

Have you completed a 3 hour humanities class? _____ Yes _____ No Grade__________

Have you completed a 3 hour social science class? _____ Yes _____ No Grade__________

Do you have at least one more credit hour? _____ Yes _____ No

If you answered "no" to any of the above questions, please explain:

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WORK EXPERIENCE: Describe your work experience, particularly any experience you might have in pre-hospital care, public safety or health care.

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How did you learn about our MICT program? ______________________________________________

PROGRAM SCHEDULE SELECTION:

_____ Evening Schedule – Butler Community College at Andover Campus – starts January 2008

_____ Day Schedule – Winfield – starts January 2008 -- (location may change)

_____ Day Schedule – Winfield – starts January 2009

Would you consider the other schedule if needed? _____ Yes _____ No _____ Maybe

I verify that all of the information provided is, to the best of my knowledge, accurate. I also acknowledge that a criminal record check will be required in the future before performing patient care in the hospital setting.

SIGNATURE: _____________________________________________

SUBMISSION: Submit this application, at least two letters of recommendation and a copy of your EMT certification. Mail completed applications to:

Chris Cannon , Department Chair
Cowley College
1406 East 8th
Winfield, Kansas 67156

Official transcripts for high schools and colleges must also be sent to our registrar.

Incomplete applications will not be considered.

 

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