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EMS Program Application
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EMS Program Application
for Admission
EMS Program Application for Admission
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Program Information:
Year Applying For:
*
2024
2025
2026
Semester Applying For
*
Spring
Summer
Fall
Program Applying For
*
EMT (Spring and Summer only)
AEMT (Fall Only)
Paramedic (Fall or Spring)
Your Information:
Name:
*
First
Last
Laurel Ridge Student ID #:
*
Email:
*
Phone:
*
Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Are you a High School Graduate?
*
Yes
No
Year of High School Graduation:
*
High School Name:
*
High School City and State:
*
Do you have a GED?
*
Yes
No
Date of GED Completion:
*
Certification Information:
Copies of your Virginia and/or National Registry Certification, CPR Card and Driver’s License must be provided at the end of this application process (via email or snail mail).
Current Certification:
*
None
EMT
AEMT
EMT-I
Paramedic
Virginia and/or National Registry Certification Number:
*
Virginia and/or National Registry Certification Expiration Date:
*
CPR?
*
Yes
No
CPR Card Expiration Date:
*
Agreement
By electronically submitting and initialing this form below, I affirm that all information is true and correct. I understand that enrollment in the EMS Program is conditional based on successful completion of a criminal background search, drug screen and fingerprinting. Today’s Date: 11/23/2024
Applications are not complete until all required documents are received. The deadline for completed applications is due at least two weeks prior to the start of the semester.
Initial:
*
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