Emergency Medical Services Program

Emergency Medical Services Program - Application

Albany State University

Darton College of Health Professions

ASU-West Campus

2400 Gillionville Rd

Albany, GA 31707

Please Note:

UPON SUBMISSION, ALL APPLICATION PACKETS BECOME THE PROPERTY OF THE DARTON COLLEGE OF HEALTH PROFESSIONS

ASU ID#:

(Optional)

Course Interest:*

EMT/AEMT (This is the entry-level EMS program)

Paramedic (Must currently be an AEMT or EMT with successful completion of an AEMT program)

Demographic Information:

Honorific:

Ms.

Mrs.

Mr.

Last Name:*

First Name:*

Social Security #:*

Date of Birth:*

Address:*

City:*

State:*

Select

Zip:*

Home Phone #:*

Phone

Cell Phone #:*

Phone

Preferred E-mail Address:*

Have you taken any of the following courses? Check all that apply.*

BIOL 1100K (Human Anatomy and Physiology for the Health Care Professional)

BIOL 2411K (Human Anatomy and Physiology I)

BIOL 2412K (Human Anatomy and Physiology II)

I have not taken any of these courses.

Briefly list any medical and/or emergency services experience:*

Required Documents Upload

PLEASE USE THIS SECTION TO ATTACH THE FOLLOWING REQUIRED DOCUMENTS:

In addition to meeting the requirements for general college admission, prospective EMS students must submit the following information to their Emergency Medical Services Program advisor:

1. Copy of driver’s license

2. Copy of high school diploma or GED equivalency certificate

3. Copy of unofficial transcript(s)

4. Copy of Immunization Record to include the following:

• Hepatitis B (3 shot series)

• MMR 1&2

• Varicella (2 shot series)

• Influenza (during flu season → August thru March)

5. Copy of any current state or NREMT license(s)

6. Copy of any other certifications (i.e. NIMS, TIM, CAH, BLS, etc.)

File Upload*

Drag and drop files here or

Driver’s License?*

High School Diploma or GED?*

Unofficial Transcript(s)?*

Immunization Record?*

State or NREMT license(s)?*

Other Certifications?*

Personal Identifiable Information (PII) Notice:

All personal data and special categories of sensitive personal data collected or processed by Albany State University (ASU) must comply with the ASU Cybersecurity Program Plan, as authorized by the Board of Regents Policy Manual Section 10.4 Cybersecurity:

https://www.usg.edu/policies

Anyone suspecting his or her sensitive personal data has been exposed to unauthorized access, report your suspicion to:

LegalAffairs@asurams.edu

Otherwise, questions concerning GDPR can be forwarded to LegalAffairs@asurams.edu. Typing your name in the box below and submission of this application provides consent to and acknowledgment of the ASU Data Security and Privacy Policy.

Please check the box below to indicate that you have read and understood the PII policy above.

Personal Identifiable Information (PII) Consent:*

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