Academy Application

Full Legal Name*

Prefix First Last Suffix

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Phone*

Email*

Employer

Work Address

Street Address Address Line 2 City State ZIP Code

Work Phone

OK to contact me at work?

Yes
No

Other Phone

Education Level:*

High School Diploma
GED
Some College
College Degree

Current Certification:*

EMR
EMT
EMT-Intermediate
None

Course Requested:*

EMR
EMT
Advanced EMT
CE
Other

Electronic Applicant Signature*

Please type your name.

CAPTCHA

Information obtained from this form is authorized by state and federal laws prohibiting discrimination on the basis of race, sex, age, religion, national origin or handicap. *Note: Date of birth is requested to verify that the applicant will be 18 years of age at the time of NR/TDSHS registry (for EMS certification courses), in accordance with state law and NR/TDSHS Rules.

Phone

This field is for validation purposes and should be left unchanged.

Non-Profit Air Ambulance

Our Staff

Patients Stories