Paramedic Program Application Form | Allied Health EMS

*First Name:

(required)

Middle Name:

*Last Name:

(required)

*Email Address:

(required)

*Home Phone Number:

(required)

Cell Phone Number:

*Address:

(required)

*City:

(required)

*State:

(required)

*Zip:

(required)

Educational Background

*High School:

Year Graduated:

(both fields required)

College:

Hours Completed:

Degree:

Year Graduated:

Other Education (describe):

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 I class?

Yes No Grade

Have you completed the English Composition II class?

Yes No Grade

Have you completed the computer class?

Yes No Grade

Have you completed a 3 hour ethics class?

Yes No Grade

Have you completed a 3 hour psychology class?

Yes No Grade

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

Work Experience:

Describe your work experience, particularly any experience you might have in pre-hospital care, public safety or healthcare:

Program Schedule selection:

16-Month Schedule - Andover (Partnership with Butler Community College) - Starts June 2018
12-Month Schedule - Winfield - Starts January 2019
16-Month Schedule – Winfield Online – Starts June 2019

Verify

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.

*Incomplete applications will not be considered.