EMT Student Application Form

Application: CSUDH EMT Training Program

Documentation and Medical Requirements for EMT Students

Thank you for your interest in the Emergency Medical Technician (EMT) Training Program at 好色先生 Dominguez Hills! Please complete and submit this application, along with document copies to Extension Programs, College of Continuing and Professional Education, 好色先生 Dominguez Hills.

Before starting the application process, be sure to review the course prerequisites on the EMT Program page.

Steps to Apply:

Complete and submit the CSUDH EMT Training Course webform application below. Fields with * asterisks are required.

Review the upcoming schedule and provide the 5-digit Course Record Number (CRN) for the term in which you intend to start in the Application Term field. (View example 鈻�)
Upload copies of the required documentation to our Dropbox in the Prerequisite Verification section.
- Photos/scans of original documents are acceptable using the following formats only:
  .zip, .doc, .png, .gif, .jpg, .pdf
- Attach all necessary documents, and sign in to Dropbox or confirm your name and email address before submitting. (View example 鈻�)
- Allow approximately three (3) business days for review of submitted documents.
Approximately two (2) business days after an application has been submitted:
An email from the Extension Programs department will confirm the submission has been successfully received.
Upon acceptance into the program, a permission number and registration instructions will be provided.

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听 Application Term	鈥斕�
*Requested Term CRN Number:	[Provide the 5-digit course number from the Schedule - see example screenshot]

听 Student Applicant Information	听鈥�
*Last Name:
*First Name:
*Date of Birth:
*E-mail听Address:
Contact Phone:
*Full Mailing Address:	[Include Street Address, City, State and Zip Code]
CSUDH Student ID (if available):
CSUDH Toromail听Address (if available):

听 Prerequisite Verification	听鈥�
Provide copies of the following items: 鈥� Photo/Scan of valid Driver's License or state picture ID 鈥� Photo/Scan of H.S. Diploma or GED Award 鈥� TB Test Reading dated within 6 months of class start 鈥� Proof of Hepatitis B Vaccination 鈥� Photo/Scan of American Heart Association CPR-BLS Card
*High School Graduation Date or GED Award Date:
*Driver鈥檚 License or Identification Number:
*Negative TB Test Date:
*Hepatitis B Vaccination Date:
*American Heart Association CPR-BLS Number:
*American Heart Association CPR-BLS Expiration Date:

听 Student Signature	听
Certifying/Acknowledgement Statements: I certify that the information submitted in this application is true and correct to the best of my knowledge I acknowledge the following: Social Security Number and criminal background check will be completed prior to registering as an EMT and/or obtaining employment. Note: some ambulance ride along providers require background check for fieldwork Students must meet the attendance, test/quiz score, and ride along requirements outlined on program website in order to pass this course with a grade of PR and become eligible to sit for the National Certifying Exam (NREMT) Physical requirements for the EMT Training Course and employment include the ability to lift, carry, and balance up to 125 pounds, and to walk, bend, and stoop on uneven terrains. Students must purchase the course uniform (approximately $150) during the first week of class, and wear to every class session and ride along Regular access to personal computing device and internet is required Assessments are virtually proctored by Proctorio via audio, video and screen recording
*Student Name
*Student Initials (signature)
*Date

听(Please do not click the Submit Application button more than one time.
Please note this application does not get stored/saved in the web browser.)

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好色先生

Emergency Medical Technician (EMT) Training Course

Application: CSUDH EMT Training Program

Documentation and Medical Requirements for EMT Students

Steps to Apply:

听 Application Term

听 Student Applicant Information

听 Prerequisite Verification

听 Student Signature

Certifying/Acknowledgement Statements:

Have questions?