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VU Jasper EMT Application

This course is designed for individuals desiring to perform emergency medical care. It will use the United States Department of Transportation National Education Standard for Emergency Medical Technician. Students meeting appropriate standards will be qualified to take the State of Indiana and National Registry test for certification as Emergency Medical Technicians.

Prerequisite(s): Students should be at least 18 years of age; and completion of or concurrent enrollment in a CPR certification course, or instructor approval.

Submitted Date

Student Type

Round (Term)

Major

Educational Goal

Campus

First Name

Preferred Name

Middle Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Permanent Address

Same as Mailing Address

Country

Street

City

Region

Postal Code

Birthdate

Email Address

Phone Number

Gender

Ethnicity: Are you Hispanic or Latino?

Country of Citizenship

US Residency Status

Check all that apply to you:

Law Enforcement Officer

Fire Fighter

High School Information

High School Name

High School Graduation or GED/TASC Date

Which of the following best describes your reason for attending VU as a non-degree seeking student?

Explain

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Email

College Expulsion/Suspension

*Have you ever been expelled or academically disqualified from VU?

Yes

*Have you ever been dismissed from any other institution for disciplinary reasons?

Yes

*University/college at which the incident occurred:

*In your own words, please provide the date and explain the events that lead to the expulsion/suspension.

Felony Charge

*Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime?

Yes

*Please indicate the felony charge:

*In your own words, please provide the date and location of the incident(s) and explain the events/circumstances leading to the felony charge.

Signature

I understand that to register for courses with prerequisites, I must meet the same academic guidelines as degree-seeking students and that I may be required to take a college placement exam.

Signature