Paramedic Program Online Application
First Name
Middle Name
Last Name
2021 Paramedic Classes
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2/22/21 - 8//22 Mondays 9-5
7/7/21 - 08/22 Wednesdays 9-5
10/28 - 11/22 Thursdays 9-5
Demographic Information
Street
City
State/Province
...
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces
Armed Forces Americas
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
N/A
Zip/Postcode
Birth Date
Country
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AFGHANISTAN
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTIGUA AND BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOSNIA AND HERZEGOVINA
BOTSWANA
BRAZIL
BRITISH VIRGIN ISLANDS
BRUNEI
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
CHINA
COLOMBIA
COMOROS
CONGO, DEMOCRATIC REPUBLIC OF THE
CONGO, REPUBLIC OF THE
COOK ISLANDS
COSTA RICA
CROATIA
CUBA
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN
IRAQ
IRELAND
ISRAEL
ITALY
IVORY COAST
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOSOVO
KUWAIT
KYRGYZSTAN
LAOS
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAO
MACEDONIA
MADAGASCAR
MALAYSIA
MALAWI
MALDIVES
MALI
MALTA
MARSHALL ISLANDS
MAURITANIA
MARTINIQUE
MAURITIUS
MEXICO
MICRONESIA, FEDERATED STATES OF
MOLDOVA
MONACO
MONGOLIA
MONTENEGRO
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMIBIA
NAURU
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NORTH KOREA
NORTHERN MARIANA ISLANDS
NORWAY
OMAN
PAKISTAN
PALAU
PALESTINE
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILIPPINES, REPUBLIC OF
POLAND
PORTUGAL
PUERTO RICO
QATAR
ROMANIA
RUSSIAN FEDERATION
RWANDA
SAINT KITTS AND NEVIS
SAINT LUCIA
SAINT VINCENT AND THE GRENDINES
SAMOA
SAN MARINO
SAO TOME AND PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA AND MONTENEGRO
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SOUTH KOREA
SPAIN
SRI LANKA
SUDAN
SUDAN, SOUTH
SURINAME
SWAZILAND
SWEDEN
SWITZERLAND
SYRIA
TAIWAN
TAJIKISTAN
TANZANIA, UNITED REPUBLIC OF
THAILAND
TOGO
TONGA
TRINIDAD AND TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TUVALU
TURKS AND CAICOS ISLANDS
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES OF AMERICA
URUGUAY
UZBEKISTAN
VANUATU
VATICAN CITY
VENEZUELA
VIETNAM
VIRGIN ISLANDS, U.S.
YEMEN ARAB REPUBLIC
ZAMBIA
ZIMBABWE
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Fire Department
Hospital
Employer
Previous Student
AZ Department of Health Services
Permanent Contact Info
(if different from above)
Street
City
State/Province
Zip/Postcode
Country
Phone
Emergency Contact Info
Contact Name
Relationship
Cell Phone
Work Phone
Home Phone
Academic Information
High School Diploma/GED Completed?
Yes
No
Not Selected
I certify that the information given in this application and all required documentation provided is complete and accurate. I also understand that to make false or fraudulent statements in this application may result in denial of admission. If admitted to the Arizona Academy of Emergency Services, I agree to abide by the policies, rules, and regulations of the Arizona Academy of Emergency Services. I will notify the Arizona Academy of Emergency Services staff of any changes to the information in my application as soon as possible.