Check Programs for which you are applying Application Period
Emergency Medical Services- Paramedic
Jan 2- May 31- Fall Start
Technical Certificate
Emergency Medical Technician EMT
Jan 2- May 31- Fall Start
Certificate of Proficiency- EMT
Jun 1- Sept 30- Spring Start
Certificate of Proficiency- EMT
Dec 1- Mar 31- Summer Start
Certificate of Proficiency- EMT
If you are applying for EMT, do you intend on working toward a technical certificate in Paramedic in the future? Yes
Date of Birth:
Print Name in Full:
Last Name First Name Middle Name
Number & Street City State Zip
Cell Phone:
Home Telephone:
Social Security Number:
Please Print Legibly
NPC Email Address:
Personal Email Address:
Date of desired admission to this program:
Have you previously applied to this program?
Have you ever taken a college entrance examination?
Yes No Date:
ACT SAT Compass Accuplacer Other:
List information concerning high schools, coll
eges, or universi
ty attended:
Name of Institution City & State Dates (From - To) Degree Received
List Work Experience:
Employer Location Dates (From - To) Description of Work
If applying for Paramedic: Arkansas EMS Number: Expiration:
Do you have any formal medical training? Yes No
If yes, please list licesnse type and license number:
Are you currently a volunteer firefighter? Yes No If yes, Where?
(Please complete page 2)
Y:\ NURSING\ SECRETARY_FOLDER\ AccessibleDocuments\ EMS\ EMT_application_NPC 2019_2020.docx (Revised 19)
How did you hear about this program?
Last Name First Name
Cell Phone: Work Phone:
Because a person can find it difficult, if not impossible, to obtain a license to practice as an EMT/PARAMEDIC
under certain conditions, please answer the following questions:
1. Have you ever been convicted of a felony or a misdemeanor? Yes No
2. Do you have a felony charge pending? Yes No
If yes on either of the previous questions, submit an explanation of the felony or misdemeanor, including dates and specific
details. Place it in a sealed envelope addressed to the Dean of Nursing and Health Sciences and attach it to this application.
3. Have you ever had an EMT/
Paramedic license in the past? Yes No
For your application to be considered complete you must:
1. Apply to NPC if you are not currently a student.
2. Attach official transcripts from all colleges or universities attended, including an unofficial transcript from NPC.
3. Attach a copy of standardized test scores (Accuplacer, ACT, or SAT) if you have never attended college.
4. Attach a copy of any certifications that you hold (CPR, PALS, PEARS, ASLS, etc…).
Please save the completed copy of this application and print. To finalize this application, submit a signed
hard copy to the Division of Nursing & Health Sciences.
Refer to the NPC website or the NPC catalog for the essential functions and/or technical standards required for each Nursing
and Allied Health program before submission of this application. National Park College provides academic accommodations as
mandated by ADA and 504. Please contact NPC’s Compliance officer at 760-4227 for reasonable accommodations under the
American’s with Disabilities Act (ADA) and for disability assistance information.
Falsifying any records pertinent to this application can lead to ineligibility or immediate dismissal from the Emergency Medical
Sciences programs. I understand that falsifying my application is dishonest and demonstrates a lack of integrity which could
compromise my acceptance and/or licensure. (PLEASE INITIAL)
I understand the health care industry requires a criminal background check and drug screening upon employment and random
drug testing throughout employment. I also understand that a criminal background check will be required at the time of
admission to the program. I understand that the Substance Abuse Policy of NPC Emergency Medical Science Programs may
require drug testing during my enrollment for the following reasons: 1) Upon admission into the program. 2) Scheduled testing at
unannounced times throughout the program. 3) Random testing as required by the clinical agencies. 4) For cause.
National Park College in compliance with Title VI of the Civil Rights Act of 1964 and Title IX of the Education Amendments of 1972 Higher Education Act does not discriminate on the basis of race, color, national
origin, sex, or qualified handicap in any of its policies, practices, or procedures. The provision includes, but is not limited to, admissions, employment, financial aid, and other educational services. Any person
having inquiries concerning NPC compliance with Title IX is directed to contact the Dean of Students Office on the second floor of the Student Commons or by telephoning (501) 760-4229.
Return the Complete Application and all Documents to:
Nursing & Health Sciences Division- Frederick Dierks
101 College Drive: Hot Springs, AR 71913