Ellen Vest, MA, EMT-P, NCEE
EMS Program Head
12745 College Drive
Glenns, Virginia 23149
(804)
75
8-6777
evest@rappahannock.edu
Classes are scheduled to begin on August 24, 2020, with online sessions in Zoom on Monday
and Wednesday evenings from 7p-9p. There will be 2-3 Saturday labs a month (locations TBD)
from 9a-5p. A schedule will be provided.
2020-2021 BASIC LIFE SUPPORT PROGRAM APPLICATION FALL SESSION
Applying for EMT
Full Legal Name: _______________________________________Date: ____________
Home Address: _________________________________________________________
______________________________________________________________________
Home Phone: ______________ Work Phone: __________Cell Phone: _____________
E-mail Address ________________________________Last 4 of SS#____________
Date of Birth: ________________ School ID: ___________________Shirt Size_______
If currently certified at any level or in any state: Please attach a copy of card
*Current EMS Certification Level: _____________________
*Certification Number: ______________________ Exp Date: ______________
Type of Current CPR Course (provider and course): ____________________________
Date Card Expires: ______________ (Please attach a copy of card-front and back.)
EMS Affiliation: Agency, if applicable: _____________________________________
Have you ever been convicted of a felony involving a sexual crime OR have you ever
been convicted of any other felony under the laws of Virginia or of the United States
within the last five (5) years? _________ Yes __________ No
I understand that all information on this application is subject to verification and I
consent to a criminal history background check.
I understand that falsification of any portion of this application may be reason for
termination from the EMS program.
I certify the above stated information is accurate to the best of my knowledge.
____________________________________ _________________
(Signature) (Date)
An information session has been scheduled in Zoom on August 6
th
at 7:00pm. Contact Ellen
Vest at evest@rappahannock.edu to register for this session.
