EMT Course Application

EMT COURSE APPLICATION

Your Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Home Phone

Cell Phone(Required)

Email Address(Required)

Emergency Contact(Required)

Emergency Contact Number(Required)

Relationship to Emergency Contact(Required)

Course Selection(Required)

Current Employer(Required)

Health System Employee Referral: (if any)

Are you a past Medstar Education student? If yes, when?(Required)

Do you require any special ADA accommodations? If yes, please specify(Required)

Have you ever been convicted of, pled no contest to, or guilty of a felony? If yes, please specify(Required)

Upload Your Driver's License Front Side(Required)

Accepted file types: pdf, jpg, png, Max. file size: 200 MB.

Today's Date(Required)

Upload Your Diploma or GED (photo or pdf)(Required)

Accepted file types: pdf, jpg, png, , Max. file size: 200 MB.

Upload Your Immunization Records(Required)

If not in your possession, this should be available from your doctors office, recent school, or public health department.

Accepted file types: pdf, jpg, png, Max. file size: 200 MB.

Upload Tuition Advance Promissory Note

Must be signed

Accepted file types: pdf, jpg, png, Max. file size: 200 MB.