ALS Program Interest Form

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Student interest form in EMS program at Tidewater Community College

Email *

Anticipated enrollment

as soon as possible

Spring

Summer

Fall

Other:

First Name *

Last Name *

Personal email *

VCCS email (if a current student in the VCCS system)

Physical address (street) *

City *

State *

Zip Code *

Primary Phone number *

Other phone number

EMS training interest (Check all that apply) *

AEMT certification

Paramedic certification

Not sure - need more information

Paramedic AAS Degree

Credit for Prior Learning (current holders of any level of EMS certification)

Other:

Required

Anticipated program enrollment (select programs you are interested in enrolling in) ALL PARAMEDIC OPTIONS include AEMT education *

Accelerated Paramedic Program (6 months - Monday through Friday, 8 hours a day)

Boot Camp Paramedic Program (12 months - student attends Tuesday or Wednesday, and Thursday or Friday, 8 hours each day)

Semester Paramedic Program (18 months - student attends 2 nights a week 5 hours each night)

AEMT Only

Required

A copy of your responses will be emailed to the address you provided.

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