RESPONDRIGHT EMS ACADEMY
APPLICATION EMT REFRESHER
Applications must include all items to be considered for admission
COURSE APPLIED FOR (start date): ________________________
Please print or type. Complete all sections/do not leave any sections blank
Are you enrolling in this EMT refresher class for: Relicensure Re-entry
How did you hear about RespondRight? News Article Podcast Fire Department
Family/Friend Web Site
CURRENT EMT-B LICENSE NUMBER: ___________________ Exp. Date: __________
Include a copy of your EMT-B License or Course Completion certificate
PERSONAL INFORMATION:___________________________________________________
Full Name: ___________________________________________________
Current Address: _______________________________________________
City: State: Zip Code: ___________________________________________
Home Telephone: _______________ Alternate Telephone: ____________
Social Security Number: ________________ Date of Birth: _____________
Email address (required): __________________________________________
Are you: a U.S. Citizen? ______ Legally able to work in the U.S.? _______
IN CASE OF AN EMERGENCY NOTIFY:________________________________________
Name: _______________________________________________________
Relationship: __________________________________________________
Address: ______________________________________________________
City: _________________________State: _________ Zip Code: ________
Home Telephone: ______________ Alternate Telephone: ______________
RespondRight
EMT Refresher Application

HAVE YOU EVER BEEN CONVICTED OF A FELONY?___________________________
YES____ NO ____
List all misdemeanors and/or felony convictions and the dates they occurred:
Felony/misdemeanor Date
______________________________ _____________________________
______________________________ _____________________________
Attach additional sheets as necessary.
EDUCATIONAL INFORMATION:______________________________________________
Type of School
High School or GED
Name and Location
(City/State)
N/A
Major Field of
Study
N/A
Diploma or Degree
Completed
□Yes (diploma or GED)
□No
College/University
Other
□Yes Degree: __________
□No # Hours: _________
□Yes
□No
EMS Training Programs:
(List Name of Program, Location, and Date)________________________________________
Program Location (City, State) Date Completed
____________________________ ________________________________ _______________
____________________________ ________________________________ _______________
____________________________ ________________________________ _______________
____________________________ ________________________________ _______________
RespondRight
EMT Refresher Application

EMPLOYMENT INFORMATION:______________________________________________
List current and most recent employment experiences including military and volunteer services.
1: Company Name: _____________________ Job Title: _______________________________
City/State: ____________________________ Telephone Number: _______________________
Dates of Employment: ___________________________________________________________
2: Company Name: _____________________ Job Title: _______________________________
City/State: _____________________________Telephone Number: _______________________
Dates of Employment: ___________________________________________________________
3: Company Name: ____________________Job Title: _________________________________
City/State: __________________________ Telephone Number: _________________________
Dates of Employment: ___________________________________________________________
RespondRight
EMT Refresher Application

COURSE FEES:
EMT-B Refresher Tuition: $450.00
(Includes a Non Refundable $25 Application Fee)
Book: $105.00 (Optional)
Send check or money order to:
RespondRight
5988 Mid Rivers Mall Dr
Suite 133
St. Charles, MO 63304
Credit Card Payments:
I authorize the charge of this amount $______________ to be billed to my credit card. I agree to pay the above total amount according to card issuer agreement.
Visa or
Mastercard Name on Card: _________________________________________
Card #: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Exp. Date: ____ / ____ 3 Digit CVV Code: __________
Billing Zip Code: ____________
Signature: _____________________________________________
I hereby affirm and declare that the information provided in this application is true and correct to the best of my knowledge and that any fraudulent entry may be considered sufficient cause for rejection from this program.
Applicant Signature:_________________________________________________________
Date: _____________________________
RespondRight
EMT Refresher Application