New 2022 EMT Program Application

2022 EMT Program Application

Enrollment Information

Please insert your full legal name as it appears on your Social Security card.

First Name

Middle Name

Last Name

Social Security No

High School Diploma/GED Completed?

Yes No Not Selected

Contact Information

Street

City

State/Province

Zip/Postcode

Country

Birth Date

Home Phone

Cell Phone

Program Information

Program

How would you like us to contact you?

What Payment Option are you most interested in?

You can always change any time up to the first day of class.

You will choose your class Start Date on the next page.

Emergency Contact Information

Contact Name

Relationship

Home Phone

Cell Phone

Applicant Signature

I hereby certify that I have completed this form, that the information I have provided is true and accurate to the best of my ability, and I wish to sign electronically.

Applicant Signature

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.

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