EMT Admission Form

REQUEST FOR EMT ADMISSION

(Please print or type)

Name:
Mailing Address:
Home Telephone:
Current Employer:
Position:
Have you had other medical or Allied Health Training or experience?			___Yes ___No. If yes, Please state where and when: _________________________________
Can you attend a class that meets full time( Including approximately 4 weeks classroom from 7:30am-3:30pm; 1 week rotating shifts during hospital experience, 7am-3pm, 3pm-11pm and 11pm-7am; and 1- 24 hour shift )? ___Yes ___No
Of the class dates listed on the EMT Course Schedule, which class is your 1st choice?______________ and 2nd choice? __________________
What do you intend to do with your EMT training/certification? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Attach a copy of the El Centro Testing Scores in order to be considered for enrollment.

CONTINUED

"I attest that the above information is true to the best of my knowledge. I will notify the Program Director at UT Southwestern Emergency Medicine Education in writing if any of the above information changes."

Signature _____________________________

Date__________________________________

Return to:	EMERGENCY MEDICINE EDUCATION
	Admission Coordinator
	UT Southwestern Medical Center at Dallas
	5323 Harry Hines Boulevard-MC 9134
	Dallas, Texas 75390-9134
	(214)648-5246

FOR OFFICE USE ONLY
Date Received
Admission Priority
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