Emergency Medical Tech (EMT) Registration Form
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Name *
Address *
Phone Number *
Email Address
Date of Birth *
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Do you have a high school diploma or GED. If a student needs to test the ATB Exam due to not having the high school education requirements, you need to schedule with First Lady Permenente records department as soon as possible before SCOE provides acceptance into the program. *
Are you a high school senior who will graduate this school year?
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Are you currently enrolled in the Come Back Kids Program or did you receive your high school diploma from the Come Back Kids Program?
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Are you currently enrolled in Project YES?
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Do you receive CalFresh, CalWORKs or cash aid? * *
Are you a citizen of the United States? *
Do you speak any other languages besides English? *
Do you foresee any circumstances that may interfere with your ability to complete the course? *
Please note that this course will require a drug test prior to the start of the program in order to work in the hospitals or doctor’s offices. Additional requirements for clinical rotations include: Background check- mybackgroundcheck.com student version, Negative TB skin test 1 and 2 or quantiferon TB gold blood test, Physical, Immunization record, Current flu vaccine 2021/2022 or waiver, Covid-19 vaccination record - Dose 1 and Dose 2 plus booster if eligible from 6-months of last dose. Required for clinical rotations before 7/26/2022
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I certify that my answers are true and complete to the best of my knowledge. If this application leads to enrollment, then I understand that false or misleading information in my application or interview may result in my release from the program.
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