EMT Application - CORRECTED

EMT Application

**PLEASE NOTE: Submitting the application DOES NOT guarantee your seat in the class. Your seat will only be secured ONCE FULL TUITION OR THE REQUIRED DEPOSIT HAS BEEN PAID. You can make this payment during your ADMISSIONS APPOINTMENT, which you'll be able to schedule AFTER your application has been completed and submitted.**
Enrollment Status*
Application*
Applicant Name*

First NameMiddle NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Email Address*
example@example.com
Gender*
Date of Birth*

MonthDayYear
Date
Last four digits of Social Security Number*
Ethnicity

AsianBlack/African descentEast IndianLatino/HispanicMiddle EasternNative AmericanPacific IslanderWhite/Caucasian (non-Hispanic)Other
Level of Education Completed*

General Education DiplomaHigh School DiplomaSome CollegeTwo Year DegreeFour Year Degree
Citizenship*

U.S. CitizenPermanent ResidentStudent VisaOther
Have you Ever Been Convicted of a Felony?*

YesNo
If yes, Please Explain*
Student Program Objective*

Job RelatedPersonal Enrichment
If job related, where do you currently work*
Date of Hire*
Supervisors Name*
Phone Number*
Please enter a valid phone number.
Have You Ever Attended EMT School Before?*

YesNo
If yes, where did you attend?*
What Year?*
Have you ever attended Fire School?*

YesNo
If yes, where did you attend?*
What Year?*
Certificate obtained?*

YesNo
Do you work for a(n) EMS or Fire Department?*

YesNo
If yes, what department?*
Month/Year of hire*
Are you younger than 18 years of age?*

YesNo
Student Signature*

Powered by Jotform SignClear
If under 18 years of age, a Parent/Guardian Electronic Signature is REQUIRED.
Parent/Guardian Signature*

Powered by Jotform SignClear
If under 18 years of age, a Parent/Guardian Electronic Signature is REQUIRED.
Select Course
Application Fee

Pay Application Fee

Application Fee*

Pay Application Fees

$150.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

7741 N. Military Trail, Suite 4/5, Palm Beach Gardens, FL 33410

PH: (561) 283-0400

FX: (561) 229-1066
Should be Empty: