Request edit access
Emergency Medical Telecommunication/Responder
Name (First, Middle, and Last) *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Base School *
Grade *
Address (Street, City, State, Zip Code) *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
GPA *
How many days of school did you miss last year? *
Explain in 2-3 sentences why you want to take this course. *
Your answer
Student ID Number (Lunch Number) *
Your answer
Provide the name of a teacher from your base school that can provide a character reference. *
Your answer
Provide the teacher’s email address. (Ex. John Smith-Jsmith@bedford.k12.va.us) *
Your answer
What is your career goal? (What do you want to do for a living?) *
Your answer
Is this BSTC course your 1st, 2nd, or 3rd choice> *
Explain the roles and responsibilities of an EMR/dispatcher? *
Your answer
What is your greatest weakness? *
Your answer
What is you greatest strength? *
Your answer
Tell about a difficult situation and how you handled it. *
Your answer
How do you learn best? *
Your answer
How old are you? *
Your answer
When is your birthday? *
MM
/
DD
/
YYYY
Have you ever been convicted of any felonies? *
I understand EMR/dispatcher is a very rigid course and I must do the following: maintain a minimum grade of 80%, attend class and be present for a minimum number of hours, complete clinical hours after school/weekends. I understand that failure to meet the required standards makes me ineligible to test for my EMR/dispatcher certification and could result in dismissal from class. *
How did you hear about this course? *
Submit
Never submit passwords through Google Forms.
This form was created inside of Bedford County Public Schools. Report Abuse - Terms of Service - Additional Terms