Indianapolis Emergency Medical Services

Indianapolis Emergency Medical Services

Paramedic Science Program

APPLICATION for ADMISSION

Date ____/____/_____

I am applying for program admission in: o January 2014 o August 2014

o I have no preference

PERSONAL

NAME Last / First / M.I.
EMAIL ADDRESS (Current and read on a regular basis)
ADDRESS
CITY / STATE / ZIP / COUNTY
PHONE (Home) / CELL PHONE
SSN / DOB
/ /
EMERGENCY CONTACT NAME AND RELATIONSHIP / EMERGENCY CONTACT NUMBER
DRIVERS LICENSE NUMBER / CPR CARD (Circle One): EXPIRES:
Yes No
EMT CERTIFICATION NUMBER (Provide one copy)
Initial Date of Certification / CERTIFICATION EXPIRATION DATE
/ /
CURRENT EMS PROVIDER – include station and or assignment / SHIFT
NUMBER YEARS AT CURRENT EMPLOYMENT:

Applicant, select three possible dates before September 1, 2013 to sit for the HOBET

______, 2013 / ______, 2013 / ______, 2013

Educational Background:

Educational institution / Term of
Entrance / Term of
Departure / Degree
Received
High School:
Previous Institution(s):
Current Institution(s):

* Please attach transcripts that verify the following requirements:

Class / Course Number and Title / Cr. Hrs. / Institution Attending
English W131 or equivalent with a “C” or better.
Math 110/111 or equivalent with a “C” or better.
Human Anatomy and Physiology or equivalent with a “C” or better.

M:\emsed\Paramedic Class All Forms and Documents\IEMS Application January 2014.docx