UACCH EMS Program Application
Thank you for your Interest in the UACCH 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 UACCH Registrar's Office (870-722-8220). In order to complete this application you must first register with UACCH 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
Your answer
Current Drivers License Number
There will be travel required by the program for which the student will be responsible.
Your answer
UACCH Student ID Number
You must contact the Registrar's Office to get this number.
Your answer
Your answer
Your answer
Your answer
Zip Code
Your answer
General Education
Check all that apply
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.
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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