Emergency Responder Application Form  
Complete this form with a parent/guardian (electronic signature required)

Before applying, you should know some information about EMR.
- Its actually two courses, you need to be willing to work hard and learn a lot on your own time.
- You should be in grade 11 or 12 when taking it.
- Grades are important, but you need a good attitude and be willing to work hard.
- Biology 12 is helpful (but not required)
- To work as an EMR, there is an additional government licensing process (additional fees apply)
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Last name *
First Name *
Which SCHOOL year are you applying for? *
Required
If OTHER school year selected, specify below.
Home school *
If other school, please type it here
Street Name and # *
City *
Postal Code *
Home Phone Number *
Birthdate (dd/mm/yyyy) *
MM
/
DD
/
YYYY
Student Email *
Parent Email *
Citizenship Status *
Are you of Indigenious Heritage? *
Student Fitness Statement
The EMR program is a hands on, physical program.  At times, students may have to lift heavy weights or be on the ground for long periods of time.  Students will be exposed to real and simulated medical and traumatic emergencies.
With this in mind, please answer the following questions honestly.
Do you have any physical disabilities that may prevent your success in this course?   *
Do you have any mental health issues that may prevent you from being successful in this course? *
If you answered yes to either of the two statements above, please elaborate.
Semester Request - Note we cannot guarantee your request but will do our best *
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