General Information *Initial Class Schedule *Initial Class Schedule Spring – East Brunswick – Monday and Wednesday 8a-11a & Alternating Fridays 8a-4:30p Fall – Jersey City – Monday and Wednesday 7p-10p & Alternating Fridays or Saturdays 8a-4:30p *First Name *Last Name Date of Birth - mm/dd/yyyy *Student's Email Student's Cell Phone Student's Home Phone Address 1 Address 2 City State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip Country Please list any medical conditions you have (this will be kept confidential and used in case of emergency).: Please list any medications you take (this will be kept confidential and used in case of emergency).: Please list any allergies you have (this will be kept confidential and used in case of emergency: *Will you be enrolled in college at the time of this course? YesNo Enter your student ID # if you attend Hudson County Community College EMT Course Information *Name of EMT School *Completion Date - mm/dd/yyyy *State EMT ID Number *Expiration Date - mm/dd/yyyy *National Registry ID Number *Expiration Date - mm/dd/yyyy *Name of Primary Instructor *Phone Number Education History *Do you have a: High School DiplomaGED certificate *Date Received - mm/dd/yyyy *Name of High School Attended *City/State College, University or Graduate School *Name and Location of School 1 *Dates Attended From 1 - mm/dd/yyyy *Dates Attended To 1 - mm/dd/yyyy *Major/Minor or Subject Area 1 *Degree Received 1 *Year Received 1 Name and Location of School 2 Dates Attended From 2 - mm/dd/yyyy Dates Attended To 2 - mm/dd/yyyy Major/Minor or Subject Area 2 Degree Received 2 Year Received 2 Name and Location of School 3 Dates Attended From 3 - mm/dd/yyyy Dates Attended To 3 - mm/dd/yyyy Major/Minor or Subject Area 3 Degree Received 3 Year Received 3 Emergency Contact Information *Emergency Contact First Name *Emergency Contact Last Name Emergency Address 1 Address 2 City State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip Country Emergency Contact Phone Emergency Contact Alternate Phone Am I ready to submit? Check off each item below to make sure! When all boxes are checked you are ready to click submit. * I will be 18 years old or older before the first day of class. I will be 18 years old or older before the first day of class. I understand that I must possess personal health insurance. I understand that I must possess personal health insurance. I understand that an 80% is the passing score for all courses. I understand that an 80% is the passing score for all courses. I understand that I must maintain my BLS and NJ EMT certification throughout the entire training period. I understand that I must maintain my BLS and NJ EMT certification throughout the entire training period. I have reviewed the policy and procedure manual. I have reviewed the policy and procedure manual. I understand that the schedule is subject to modification in respect to dates, times and locations. I understand that the schedule is subject to modification in respect to dates, times and locations. I understand more than 3 absences will affect my overall grade for this course. I understand more than 3 absences will affect my overall grade for this course. I understand that I must complete clinical experience shifts in addition to the in classroom and skill lab sessions. These are required to complete the program and be eligible for the National Registry Paramedic exam. I understand that I must complete clinical experience shifts in addition to the in classroom and skill lab sessions. These are required to complete the program and be eligible for the National Registry Paramedic exam. I have reviewed, read, understand, and will comply with all documents provided on the programs website. I have reviewed, read, understand, and will comply with all documents provided on the programs website. I have internet and printer access outside of class. I have internet and printer access outside of class. I understand that I will need an electronic device with Wi-Fi internet capability in class and at home in order to complete assignments and testing I understand that I will need an electronic device with Wi-Fi internet capability in class and at home in order to complete assignments and testing. I am requesting reasonable accommodations for didactic and/or skills sessions. I am requesting reasonable accommodations for didactic and/or skills sessions. Applicant Authorization & Certification I authorize the Jersey City Medical Center/Hudson County Community College Program for Pre-hospital Medicine and its agents to obtain any information relating to the facts provided in this application from schools, employers, criminal justice agencies or other individuals. This information may include but is not necessarily limited to, academic performance, attendance, achievement, personal medical/drug use history, disciplinary action, arrest and conviction records. I release any employer, including individuals such as record custodians, from any and all liabilities that may result from the release of information to the Jersey City Medical Center/Hudson County Community College Program for Pre-Hospital Medicine. I certify that the statements provided herein are true to the best of my knowledge. I understand that any incomplete, inaccurate, misleading, false or incorrect information given in this application may result in the rejection of my application. Such information may also render an acceptance void and/or can be cause for dismissal upon discovery. I agree to submit to all pre-admission testing as required by the Jersey City Medical Center/Hudson County Community College Program for Pre-Hospital Medicine. Agree Agree *Confirm Security Question below: