EMT Class | hermann-ems

Applicant Information

First name

Last name

Address

City

State

Zip Code

Email

Phone Number

Applicant Education and Past Experience

High School Diploma or GED

Name of High School or GED Program Attended

Date of Graduation or Completion

List EMS or Fire related certifications you currently hold, if any. (Fire I, Fire II, CPR, EMD, EMR, etc.) Upload certifications below.

Current Cards or Certificates for above.

List any previous medical experience that you have, if any.

Upload at least one letter of recommendation.

Have you participated in any EMT courses in the past?

Yes

No

If yes, when and where did you take the class?

Why do you wish to take this course?

This course requires time and commitment for classroom and for clinical participation as well as study time. Are you prepared to make such a commitment?

Yes

No

This course requires physical stamina, endurance, and the ability to lift, push, pull, reach over head, squat, bend, kneel, climb, sit, stand, walk and carry patients and equipment. Can you carry out these requirements?

Yes

No

Part of training requires that procedures taught in the classroom be applied and practiced by fellow students. (Applying c-collars, backboarding, assessments, and other hands-on skills) Are you willing to allow other students to practice these on you?

Yes

No

If not, please explain why?

Where did you hear about our EMT program?

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. I understand that this agreement is a legally binding instrument upon written acceptance by Hermann Area Ambulance District.

I understand that false or misleading information in my application or interview may result in my rejection or subsequent revocation/discharge from the EMT program.

Signature

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Complete the application below or click here to access a PDF application to print.

Applicant Information

Applicant Education and Past Experience

Disclaimer and Signature

Complete the application below or click here
to access a PDF application to print.