EMT Program Application Step 1 of 9 11% EmailThis field is for validation purposes and should be left unchanged.Applicant InformationLegal Name(Required) First Middle Initial Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Are you a citizen of the United States?(Required) Yes No Have you ever been convicted of a felony crime, a crime involving dishonesty or lack of truthfulness, or involving a health service function?(Required) Yes No Please provide a detailed explanation to your answer above.(Required) EducationHigh School(Required)School NameLocationDates Attended Add RemoveDid you graduate?(Required) I have graduated high school and have my diploma I have obtained a GED I’m currently attending high school. CollegeDid you attend college?(Required) Yes No Currently enrolled College InformationCollege Attended(Required)NameLocationDates Attended Add RemoveDid you graduate college?(Required) Yes No Currently enrolled Type of degree Obtained?(Required)Type of degree Pursued?(Required) Trade School or Technical School EducationHave you attended a trade or technical school?(Required) Yes No School Information(Required)NameLocationDates Attended Add RemoveArea of study?(Required)Did you graduate?(Required) Yes No Emergency Medical Responder (EMR)Have you attended an EMR Course?(Required) Yes No Currently Enrolled EMR Course Information(Required)Course LocationDates AttendedInstructor Name Add RemoveDid you successfully complete the course and obtain EMR certification?(Required) Yes No Please explain why you did not complete the course.(Required) Military, Fire, Police, and Volunteer ServiceHave you served in the United States Military(Required) Yes No Military Service Information(Required)BranchDates servedRank at dischargeType of discharge Add RemoveFire ServiceAre you currently involved with a fire department?(Required) Yes No Fire Department information(Required)Department NameDates ServedPosition Add RemoveLaw EnforcementAre you currently involved with law enforcement?(Required) Yes No Department information(Required)Department NameDates ServedPosition Add Remove ReferencesPlease list three professional references(Required)Select the “+” Icon To Add Each Additional Reference.NameAddressPhone NumberEmailHow long have you known them? Add Remove EssayUpload a 500-word essay explaining why you would like to become an EMT. Discuss what will set you apart from the other applicants and your career goals as an EMT.File(Required) Drop files here or Select files Max. file size: 128 MB. Disclaimer and SignatureEMT Program Application Disclosure(Required)Disclaimer: By submitting this application, I acknowledge and agree to the following terms: Accuracy of Information: I certify that all the information provided in this application is true and complete to the best of my knowledge. I understand that any false or misleading information may result in the rejection of my application or, if accepted, my dismissal from the EMT program. Program Requirements: I understand that acceptance into the EMT program requires me to meet all the program requirements, including but not limited to academic performance, attendance, and adherence to all rules and regulations set forth by the St. Francois County Ambulance District. Costs and Expenses: I understand that, if accepted, I will be responsible for the $300 tuition feee ($150 due at the beginning of the course, with the remaining $150 due at the course midpoint). I am also responsible for purchasing boots, pants, a belt, and a textbook. (Assistance is available if needed) I agree to be responsible for covering these costs. Health and Safety: I understand that the EMT program involves activities that may pose health and safety risks. I agree to follow all safety guidelines and procedures to minimize these risks. I also acknowledge that I am responsible for my own health and well-being throughout the duration of the program. Limited Seating and Selection Process: I understand that seating in the EMT program is limited and not all applicants will be accepted. The selection of applicants is based on the quality of the applications and essays received. The selection process is conducted fairly and does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other protected status. Program Changes: I understand that the St. Francois County Ambulance District reserves the right to make changes to the program, including course content, schedule, and requirements, as necessary. I agree to the terms and conditionsSignature(Required)
