UAHT EMS Program Application
Thank you for your Interest in the UAHT EMS program. To be considered for the program this form must be completed prior to the class start date. This form does not register you with the UAHT Registrar's Office (870-722-8220). In order to complete this application you must first register with UAHT to get your student ID number. Incomplete applications will not be accepted.
Additional documentation is required
General Information
Name (last, first) *
Your answer
Primary Phone Number *
The best number to contact you.
Your answer
Secondary Phone Number
Your answer
Email Address *
Your answer
Age *
Your answer
Current Drivers License Number *
There will be travel required by the program for which the student will be responsible.
Your answer
UAHT Student ID Number *
You must contact the Registrar's Office to get this number.
Your answer
Address
Street *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Education
General Education *
Check all that apply
Required
College Education
These classes may have been taken traditionally, online, or concurrent credit.
Have you had training in any Health Occupations field? *
If yes please list all certifications, licensures, or courses taken in the section marked Other.
Required
Have you ever been convicted of a Felony? (There will be a criminal background check conducted by the Arkansas State Police.) *
This means you have plead guilty to or been found guilty by a judge or jury. This should include anything that may appear on your record.
Course of Study
In which program are you enrolling? *
In order to enroll in the Paramedic Program you must have a valid Arkansas EMT license.
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