Emergency Medical Sciences Application

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This application is for students who have completed an application to UA - Pulaski Tech. If you have any questions about this form or about the Emergency Medical Science (EMS) programs, please contact [email protected].

When do you plan to start your journey at UA-PTC for one of the UA-PTC Emergency Medical Sciences programs?

Full Name: (First, Middle, Last)

What are the last 4 of your social security number or UA-PTC student ID number?

What is your phone number?

What is your e-mail address?

Do you have a current Arkansas EMT card? If so, what is the number?

If no, leave blank.

Have you previously attended an EMT course? Dates, Location?

If no, leave blank.

Have you previously attended a Paramedic course? Dates, Location?

If no, leave blank.

Do you currently hold an American Heart Association Basic Life Support card? Expiration Date?

If no, leave blank.

Have you ever had a professional license on probation, suspended or revoked in healthcare or any other field?

Yes

No

If seeking the EMT license are you interested in the day or night course?

Day

Night

Not seeking an EMT certificate

If you are a current Arkansas licensed EMT, are you seeking:

Paramedic Technical Certificate

Associate of Applied Science in Emergency Medical Sciences

Both

Not seeking a Paramedic Technical Certificate or an AAS in EMS

Is there any other type of prehospital education we could assist you with?

Paramedic Program Objectives

Preceptor Information

Emergency Medical Sciences Application

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