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NTCC EMS Program
Student Information Sheet
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:  _____________________________________________________________________________
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):  _____________________________________________________________________________
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  _________________________________________________________________
Describe any experience with EMS (volunteer or paid) ________________________________________
Hobbies  _____________________________________________________________________________
Favorite Snack Food ____________________________        Favorite Sport ________________________



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:
D. Grantham, Director of EMS

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This page last updated by D. Grantham on 04/29/2015

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