Emergency Medical Technician Course Application

Emergency Medical Technician Course

Applicant Information For course of March 20, 2023 to July 13, 2023
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Age*
Driver License #*
Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Number*
Secondary Number
Student E-mail*
example@example.com
Emergency Contact Name*
Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
Parent/Legal Guardian (if applicable)
Full Name

First NameLast Name
Home Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Parental/Legal Guardian Notification & Approval Form Upload

These forms are required if the student is less than 18 years old.
Cancelof
Any additional information
Education Information
Name of High School*
City*
State*
Current Grade (if appicable)
Cumulative GPA
Please attach copy of transcript or Diploma

Cancelof
Any additional training or classes
Current Employment
Please provide your current employment status

I am a current employee of Hardtner Medical CenterI am currently employed elsewhereI am not currently employed anywhere
Current position and department
What is your hire date?
Are you wanting to work in Hardtner EMS Department?
Current Employer
Position/Department
How long have you been employed?
Have you ever been charged or convicted of any crimes other than minor traffic violations?

YesNo
If Yes, please explain in full
Do you have any disabilities that could directly affect your performance as a student? (lifting, bending, hearing, ect.)

YesNo
If Yes, please explain
Emergency Medical Services Information
Please list any certification and/or training you have in EMS. This includes BLS, ACLS, PHTLS, EMR, or past certification. Also include expiration date of the Certification.
Payment & Refund Policy

Students must pay a $150.00 nonrefunable deposit to secure their place. Payment plan can be set up of 5 payments. 1st ($500.00) due March 20, 2023, 2nd ($250.00) payment is due March 31, 2023, 3rd ($250.00) payment is due April 14, 2023, 4th ($250.00) payment is due April 28, 2023, and 5th ($250.00) payment is due May 12, 2023. Students must have all tuition paid by May 12, 2023, unless they have an agreement to have the cost payroll deducted. Hardtner Medical Center employees may have the tuition payroll deducted. However, the $150.00 deposit must be paid first. Students will get a full refund minus $150.00 and the book fee if they drop out before March 31, 2023, of class. Students will get a refund of $1,150 if they drop the class between March 31, 2023 and April 28, 2023. After April 28, 2023 no refund will be given.
I certify that my answers are true and complete. I understand that I will be subject to immediate termination from the EMT Program for any information that has been falsified.
Signature*

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Today's Date*

MonthDayYear
Date
Should be Empty:

Emergency Medical Technician Course

Parent/Legal Guardian (if applicable)

Education Information

Current Employment

Payment & Refund Policy

I certify that my answers are true and complete. I understand that I will be subject to immediate termination from the EMT Program for any information that has been falsified.