Certificate in Paramedic Science Application

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Certificate in Paramedic Science Application

Biographical Information

Name*

First Name

Initial (optional)

Last Name

Preferred Name

Gender

Female Male Not Reported

Birthdate

Native Language

Contact Information

Home Phone

Cell Phone

Mailing Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Citizenship Information

Primary Citizenship

Academic History Information

Do you have a High School Diploma or GED?

Yes No

Number of College(s) Attended

College-Level Coursework #1

Institution

Degree(s)

College-Level Coursework #2

Institution

Degree(s)

College-Level Coursework #3

Institution

Degree(s)

Do you plan to enroll as a Certificate in Paramedic Science Student?

Yes No

Start Term

Do you plan to use financial assistance?

Yes No

(Although we cannot recommend specific lenders, we do offer a list of lenders that our students have frequently used in the past. Please visit our website to see a list of our most frequently used private loan lenders. We will work with any lender of your choice even if they are not on this list)

Have you previously applied to Anna Maria College?

Yes No

Please provide the year and month of the term for which you previously applied.

Disciplinary History

Have you ever been found responsible for a disciplinary violation at any educational institution you have attended from the 9th grade (or equivalent) until now, whether related to academic misconduct or behavioral misconduct that resulted in a disciplinary action? These actions could include, but are not limited to: probation, suspension, removal, dismissal, or expulsion from the institution?*

Yes No

Please give the approximate date(s) of each incident, explain the circumstances, and reflect on what you learned from the experience.

Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime? (Note that you are not required to answer "yes" to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded or otherwise ordered by a court to be kept confidential)*

Yes No

Please provide the details of your criminal conviction or adjudication and reflect on what you learned from the experience.

Additional Information

Are you currently certified as an EMT in any state in the country and/or with the National Registry?

Yes No

Do you have a current BLS for Healthcare Providers CPR card, or will you have one in-hand prior to the first day of class?

Yes No

Do you possess a current driver’s license?

Yes No