New Student Online Application

First Name

Middle Name

Last Name

Cell Phone

Home Phone

Email

Home Address

Street

City

State/Province

Zip/Postcode

Country

Birth Date

Social Security No

Gender

Ethnicity

Marital Status

Driver's License #

DL State of Issue:

Emergency Contact

Contact Name

Address

Cell Phone

Home Phone

Work Phone

Highest Education Level

(please check all that apply)

Highest Level of Education

HS Graduation Date

How did you hear about us?

If Other, please specify

Military

Have you ever served in the armed forces?

Yes No Not Selected

Are you a Disabled Veteran?

Yes No Not Selected

Did you submit a copy of your DD214?

Yes No Not Selected

Learning Disability

(must attach doctors note)

Do you have or have been diagnosed with a learning disability:

Yes No Not Selected

Doctors Note

Do you require any special accommodations for a disability:

Yes No Not Selected

If you yes to any of the above can you provide medical documentation of the disability

Yes No Not Selected

Select Program

Program

Program Schedule

New Student:

Yes No Not Selected

Transfer Student

Yes No Not Selected

Are credits being transferred in:

Yes No Not Selected

Did you attend courses at Emergency Education Institute:

Yes No Not Selected

If yes which class:

Are you currently enrolled in a program at EEI

Yes No Not Selected

If Yes, which program:

AS in EMS

EMT

Paramedic

Cohort

Which Cohort JAN / MAY / JUNE Accelerated / SEPT

Cohort

Admissions Documents

Driver’s license

Social Security Card

High School Diploma / GED

Student Signature:

Please read before submitting application: By signing your name, you hereby acknowledge that the $100.00 Program Registration fee is nonrefundable. You agree to provide Emergency Education Institute with official High School transcripts or copy of High School diploma, College or University transcripts and all admission requirements prior to the course beginning.

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