EMT Student Application Form

Application: CSUDH EMT Training Program

Documentation and Medical Requirements for EMT Students

Thank you for your interest in the Emergency Medical Technician (EMT) Training Program at California State University Dominguez Hills! Please complete and submit this application, along with document copies to Extension Programs, College of Continuing and Professional Education, California State University Dominguez Hills.

Before starting the application process, be sure to review the course prerequisites on the EMT Program page.

Steps to Apply:

Complete and submit the CSUDH EMT Training Course webform application below. Fields with * asterisks are required.

Review the upcoming schedule and provide the 5-digit Course Record Number (CRN) for the term in which you intend to start in the Application Term field. (View example ►)
Upload copies of the required documentation to our Dropbox in the Prerequisite Verification section.
- Photos/scans of original documents are acceptable using the following formats only:
  .zip, .doc, .png, .gif, .jpg, .pdf
- Attach all necessary documents, and sign in to Dropbox or confirm your name and email address before submitting. (View example ►)
- Allow approximately two (2) business days for review of submitted documents.
Approximately one (1) business day after an application has been submitted:
An email from the Extension Programs department will confirm the submission has been successfully received.
Upon acceptance into the program, a permission number and registration instructions will be provided.

Application Term
*Requested Term CRN Number:	[Provide the 5-digit course number from the Schedule]

Student Applicant Information
*Last Name:
*First Name:
*Date of Birth:
*E-mail Address:
Contact Phone:
*Full Mailing Address:	[Include Street Address, City, State and Zip Code]
CSUDH Student ID (if available):
CSUDH Toromail Address (if available):

Prerequisite Verification
Provide copies of the following items: • Photo/Scan of Driver's License or Identification Number • Photo/Scan of H.S. Diploma or GED Award • TB Test Reading dated within 6 months of class start • Proof of Hepatitis B Vaccination • Photo/Scan of American Heart Association CPR-BLS Card	Upload Documents
*High School Graduation Date or GED Award Date:
*Driver’s License or Identification Number:
*Negative TB Test Date:
*Hepatitis B Vaccination Date:
*American Heart Association CPR-BLS Number:
*American Heart Association CPR-BLS Expiration Date:

Student Signature
Certifying/Acknowledgement Statements: I certify that the information submitted in this application is true and correct to the best of my knowledge I acknowledge the following: Social Security Number and criminal background check will be completed prior to registering as an EMT and/or obtaining employment. Note: some ambulance ride along providers require background check for fieldwork Students must meet the attendance, test/quiz score, and ride along requirements outlined on program website in order to pass this course with a grade of PR and become eligible to sit for the National Certifying Exam (NREMT) Physical requirements for the EMT Training Course and employment include the ability to lift, carry, and balance up to 125 pounds, and to walk, bend, and stoop on uneven terrains. Students must purchase the course uniform (approximately $150) during the first week of class, and wear to every class session and ride along Regular access to personal computing device and internet is required
*Student Name
*Student Initials (signature)
*Date

(Please do not click the Submit Application button more than one time.
Please note this application does not get stored/saved in the web browser.)

EMT Student Application Form

Emergency Medical Technician (EMT) Training Course

Application: CSUDH EMT Training Program

Documentation and Medical Requirements for EMT Students

Steps to Apply:

Application Term

Student Applicant Information

Prerequisite Verification

Student Signature

Certifying/Acknowledgement Statements:

Have questions?