Full Name:

Address:

City:

State:

Zip:

County of Residence:

Phone Numbers:
Home:   Cell:   Work:

Last 4 Digits of Social Security #

Date of Birth:

Age:

(Applicants must be at least 16 years of age prior to the date of the final exam for the program.)

E-Mail Address:

Education: ~ Some High School High School Diploma GED Some College College Degree Other

Course Information:

Course of Enrollment: ~ EMT Basic EMT Refresher EMT Instructor CPR Instructor CPR Instructor Refresher Practical Skills Instructor Pre-Hospital RN (PHRN) First Responder First Responder Refresher Emergency Vehicle Operator (EVOC) International Trauma Life Support (ITLS)

Course Starting Date: ~ Fall 2008 (EMT/Paramedic) May 4, 2008 (EVOC)

Affiliation:

Primary Affiliation (preferred but not required):

Station #:

Does Affiliating Company Agree to Provide Payment four Course?: Select Yes No

Affiliating Company Contact Name:

Affiliating Company Contact Phone#:

Accommodation Information:

Do you have any physical limitations which preclude you from performing the skills established by the course curriculum?

  ~ YES NO

Criminal History:

Have you ever been arrested or convicted of a misdemeanor or felony?

~ YES NO

Note: Applicants will not be denied course attendance solely because of this information. For Dept. of Health courses only, if "yes", the applicant must provide an original Pennsylvania State Police "Criminal Record Check". In some cases, the applicant will be required to provide additional documentation. A positive criminal history does not prevent anyone from enrolling in a training course, but may prevent ability for state certification. The Pennsylvania Department of Health will review individual registrations to determine eligibility for certification.

Affirmation:

By submitting this form, you certify that the facts contained in this application are true and complete to the best of your knowledge, and you understand that if accepted, falsified statements on the application may be grounds for dismissal. You authorize investigation of all statements contained herein. Further, you understand and agree that, if accepted, your enrollment may be terminated according to established course requirements.