EMS Background Questionnaire

Student Name

Date

What is your current EMS certification level?
Where did you take your EMT courses?
How long have you been certified?
Years Months
Are you currently employed with an agency utilizing your EMS certification?
Yes No
If yes,
1. Which agency are you employed by?
2. How long have you been employed by the above agency?
  Years Months
Have you served in the military?
Yes No If yes: years of service:
Have you completed any volunteer hours?
Yes No
If yes, with which agency or organization?

***Please Note***
Immunization records will be turned in during Orientation, which is the first day of the class.

PROGRAMS

VISIT

APPLY

The Blinn College District is accredited by the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC) to award associate degrees. The Blinn College District also may offer credentials such as certificates and diplomas at approved degree levels. Questions about the accreditation of the Blinn College District may be directed in writing to the Southern Association of Colleges and Schools Commission on Colleges at 1866 Southern Lane, Decatur, GA 30033-4097, by calling (404) 679-4500, or by using information available on SACSCOC's website (www.sacscoc.org).

The Blinn College District does not discriminate on the basis of race, color, national origin, sex, or disability. For information regarding Title IX, ADA, Section 504, and other anti-discrimination coordinators, see the Student Title IX page.

EMS Background Questionnaire Employment History and Emergency Contact Student Application Blinn College EMS Paramedic Program Application Recommendation Form Program Application Checklist Blinn College EMS Program Physical Form