EMS Academy Program Admission Application PLEASE NOTE: YOU MUST BE BASIC EMT CERTIFIED BEFORE APPLYING TO ADVANCED OR PARAMEDIC COURSES Program of Study:*EMTAEMTParamedicClass Time:*Monday, Wednesday & Thursday (6PM-10PM)Class Time:*Monday & Wednesday (8AM-NOON)Tuesday & Thursday (8AM-NOON)Class Time:*Monday & Wednesday (8AM-NOON)Tuesday & Thursday (8AM-NOON)Class Time:*Wednesday & Thursday (8AM-3PM)Personal Information:First Name:*Middle Name:*Last Name:*Home Address:* Address: City State / Province / Region ZIP / Postal Code E-mail Address:* Cell Phone Number:*Home Phone Number:Are you at least 18 years of age?:*YesNoDate of Birth:* Driver’s License #:*Are you a Grady EMS Employee:*YesNoEmergency Contact Information:Emergency Contact:Phone:Relationship:Requisite Course Information (AEMT/PARAMEDIC Applicants Only):Requisite Course Information:(current scope of practice)Please SelectEMT I85EMT I99AEMTName of EMT School:Location:Completion Date: State License ID#:Expiration Date: NREMT #:Expiration Date: Education HistoryHighest Grade Completed:High SchoolGEDCertificate ProgramDiploma ProgramAssociates DegreeBachelor DegreeMaster DegreeDo you have a High School diploma or GED certificate?YesNoDate Received: High School Name:City/State:College Name:City/State:EmploymentEmployer #1Employer:City/State:Job Title:Duties/Responsibilities:Length of Employment:Reason for Leaving:Supervisor:Phone:Employer #2Employer:City/State:Job Title:Duties/Responsibilities:Length of Employment:Reason for Leaving:Supervisor:Phone:References:List two (2) references (non-relatives). References will be contacted.Reference #1:Reference Name:Relationship:E-mail Address: Phone:Reference #2:Reference Name:Relationship:E-mail Address: Phone:Personal BackgroundHave you ever been arrested or convicted of a felony?*YesNoHas your driver’s license ever been revoked?*YesNoEssayIn the space above, please write at least one paragraph stating how working in the EMS industry will benefit your life:Application Fee - Non Refundable Price: $20.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Applicant Authorization and Certification I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind. I hereby certify that the information provided on this application form is accurate to the best of my knowledge and subject to verification. I authorize the schools, persons, employers and other organizations named in this application form to provide any relevant information to the Grady Paramedic Program and I declare that my answers and all statements made by me herein are true and correct.Applicant Authorization and Certification:YesNoCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms. The $20 application fee is non refundable. If you need assistance, please contact (404) 616-7414.