PLEASE READ THE FOLLOWING CAREFULLY AND SUBMIT THE APPLICATION TO AGREE TO THE FOLLOWING TERMS:

In consideration of my acceptance, I agree to conform to the rules and regulations of the School of EMS.

I understand that in order to be eligible for continuation in the program, I must agree to be properly credentialed and licensed (where appropriate), pass a criminal background check, be eligible to participate in the Federal Medicare program, submit to a TB skin test or x-ray, urine analysis and blood test to determine chemical dependency and be insurable and hold a valid driver's license.

I understand that I must have access to a computer (Windows or Mac based) with high speed internet to access online coursework, regardless of the educational format requested.

I understand that, if I have a felony and/or am listed on the Federal Exclusion list, I may not be able to obtain credentials to complete clinical internship, field internship, and/or be able to be placed within an organization for employment.

For students completing live time or clinical/field time in the State of South Dakota, you will be required to obtain South Dakota Student Status from the South Dakota Board of Medical and Osteopathic Examiners. Paramedic students in the State of Florida must hold a valid Florida EMT card prior to begining clinical rotations.

I certify that the information given by me in this application is correct and without consequential omissions and understand that any misstatement or omission will void this application and is grounds for dismissal in accordance with the School of EMS policy.

First NameRequired

Middle NameRequired

Last NameRequired

Other names by which you may be known (maiden/nickname):Required

Email AddressRequired

Social Security NumberRequired

Date of Birth (MM/DD/YYYY)Required

GenderRequired -- choose one -- Female Male Unknown

Are you of Hispanic, Latino, or of Spanish origin?Required -- choose one -- NO YES

Citizenship StatusRequired -- choose one -- Non-Resident Alien Resident Alien US Citizen

Street 1Required

Street 2Required

CityRequired

StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip CodeRequired Zip Code Extension

Phone NumberRequired Phone Number Area Code Phone Number Exchange Phone Number Number Phone Number Extension  Ext: 

Current or Most Recent EmployerRequired

Job TitleRequired

Address Street 1Required

Address Street 2Required

CityRequired

StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip CodeRequired Zip Code Extension

Phone NumberRequired Phone Number Area Code Phone Number Exchange Phone Number Number Phone Number Extension  Ext: 

What year did you graduate high school?Required

High School AttendedRequired

Current or Former College Attended:Required

Program TypeRequired -- choose one -- CME EMR EMS EMT Hybrid Live Online PARAMEDIC

Program Applying For:Required -- choose one -- EMT EMT Paramedic Paramedic Paramedic

Program Start Date:Required -- choose one -- August 2020 October 2020

Have you ever served in the U.S. Military?Required -- choose one -- NO YES

How do you plan to pay for school?Required -- choose one -- Apply for Financing Employer Sponsorship Pay In Full (Up Front)

Live Session SiteRequired -- choose one -- South Dakota

If you selected employer funded, please select your employer from the list.Required -- Education Partner Id: -- Aberdeen Fire Department : 770000184 Abilene Fire Department : 770000181 Ables Spring Fire Department : 770000009 Acadian Ambulance : 770000186 Allegiance Mobile Health : 770000160 Amarillo Fire Department : 770000043 AMR- Abilene : 770000185 AMR- Amarillo : 770000188 AMR- Arlington : 770000187 AMR- Wichita Falls : 770000189 Arizona City Fire Department : 770000190 Aubrey Fire Department : 770000067 Balentine EMS : 770000901 Booker EMS : 770000191 Brookings Ambulance : 770000192 Bullard Fire Department : 770000193 Carol Ambulance : 770000194 Carrollton Fire Rescue : 770000182 City of Carmel FD : 770001987 City of Fischers FD : 770001986 City of Noblesville : 770001988 College Station Fire Department : 770000196 Colleyville Fire Department : 770000195 Compass Military Services : 770000201 Dell Rapids Ambulance : 770000198 Emergency & Medical Training Group (UK) : 770000220 Empress EMS : 770000204 Falck- Rocky Mountain : 770000197 Grapeland Fire Department : 770000208 Heartland Ambulance Service : 770000199 International Paramedic Careers and Development (IPCD UK) : 770003091 Jacksonville Fire Department (TX) : 770000200 Lucas Fire-Rescue : 770000356 Lufkin Fire Department : 770000165 Med Fleet : 770000161 Midwest Medical : 770000179 Nacogdoches Independent School District : 770001049 North River Fire District : 770000276 Northwest Independent School District : 770001168 ORGANIZATION NOT LISTED : 770000987 PatientCare EMS- South Dakota : 770000202 PatientCare EMS- Mississippi : 770000203 Pinellas Park Fire Department : 770000183 Pro Med Ambulance : 770000809 Royal River Casino & Hotel : 770000355 Shreveport Fire Department : 770001029 St. Petersburg Fire Rescue : 770000164 Sunstar Paramedics : 770000044 SuperiorCare Ambulance : 770000390 Texas Forestry Service : 770005888 Three Rivers Ambulance Authority : 770000180 Treasure Island Fire Rescue (FL) : 770000163 Tucumcari Fire Department : 770000205 University of Texas at Tyler / School of Medicine : 770010881 UT Health East Texas : 770000206 Velocity Training : 770002512

If you are currently attending, please list your course of study. If you have graduated, please list degree or certificate earned:Required

Please type in full name & today's date:Required

How did you hear about us?Required -- select one --Compass Military Services Conference Employer Facebook Linkedin SOE Alumni SOE Employee SOE Student SOE Website Texas EMS Academy (Rey Rabagos)

Please indicate your shirt size.Required -- select one --S M L XL 2XL 3XL 4XL