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Forms

NTCC EMS Program
Student Information Sheet
 
 
PERSONAL HISTORY
Full Name_____________________________________________________Age________
Nickname or Name Preferred Called By __________________________________________
Mailing Address ____________________________________________________________
City __________________________________________  State ______ ZIP _____________
Home Phone  (_____)_________________     Cell Phone  (_____)__________________
Email Address_____________________________________________________________
If we try to contact you, list the order of contact preference:  
Cell Phone (voice contact) _________           Cell Phone (texting)           _________
E-Mail_________               Home Phone_________                              Other _________                                                                
Marital Status(circle current) :    Single     Married     Divorced     Widowed
If married, Spouse’s Name___________________________________________________
#  Children Under 18  _____# Children Over 18  ____# Children At Home _________
Allergies ________________________________________________
ANY Medical Condition we should be aware of ?   YES   /   NO     If yes, please describe:  _____________________________________________________________________________
 
EDUCATION HISTORY
Highest  Level of Formal Education Achieved (circle one)
                GED     HS Diploma     Associate Degree     Bachelor’s Degree     Master’s Degree or Higher
What YEAR was the highest level of education achieved?        _______________
What was the field of study in the degree earned?       ___________________________________
Have you obtained Vocational Training?   YES  /  NO     If so, what field(s):  ______________________________________________________________________________
What kind of coursework have you taken here at NTCC?  ______________________________________________________________________________
Are you interested in a degree program?   YES   /   NO     If so, what field(s):  _____________________________________________________________________________
 
WORK HISTORY
Are you currently employed?   YES   /   NO                   Full Time   /   Part Time   /   PRN   /   N/A
If you are employed, name of Employer  ___________________________________________________
General Hours/Days Work  ______________________________________________________________
Type of Work You Do  _________________________________________________________________
 
MISCELLANEOUS HISTORY
Describe any experience with EMS (volunteer or paid) ________________________________________
_____________________________________________________________________________________
Hobbies  _____________________________________________________________________________
Favorite Snack Food ____________________________        Favorite Sport ________________________
 

ACKNOWLEDGMENT OF NTCC-EMS PROGRAM ADMISSION POLICIES


 

I  ____________________________________________________,  have received the official  

                                (Print Student’s Name)

NTCC-EMS Admissions Policy Manual.  I affirm that understand the requirements for admission into the    program and will have all documentation completed to the best of my ability before the first day of class.
 

_________________________________________

Printed Name 

 

_______________________________                             _____________________________

Signature                                                                                                                    Date

 
____________________________________                    _____________________________________

Student’s EMS Instructor (print)                                                  NTCC EMS Director (print) 


____________________________________                     ____________________________________

 

Signature                                                                                                                   Signature                                                             


_______________________________                                           _______________________________

Date                                                                                                                        Date

 

    
    
The EMS/EMT department is located in the University Health Sciences Building on the main NTCC campus
For More Information Contact:
Mike Hudson, EMS Coordinator
903-434-8269

    
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This page last updated by M. Hudson on 04/29/2015

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