Allied Health Application - Desired Course/Program Selection - Student Demographics & Authorization

Oct 3, 2026

Allied Health Application form collects student and emergency contact information for enrollment in multiple allied-health course options, including EKG, medical billing and coding, phlebotomy, dental assistant, medical scribe, behavior health technician, and nursing aide pathways. The form requests demographics, education and employment background, criminal history declaration, and signatures authorizing EMTP to conduct required background checks. It also includes Hepatitis B vaccination understanding, with instructions to select current vaccination status, and details for program tuition, deposits, and included fees.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

Desired Course/Program

Student Demographics

Emergency Information

Educational Background

Other Training / Education

Employment Background

Other Experience

Criminal Background

Hepatitis B Vaccination Statement of Understanding

Program / Course Tuition and Fees

114 1 Red Mile Road , Lexington , KY 4 0 5 0 4 Phone : 8 5 9-3 2 7-3 6 8 7 Fax: 8 5 9-4 5 5-8 4 3 9 [www.emtp ky.com](www.emtp ky.com) Allied Health Application Desired Course/ Program: □ EKG Technician □ Day □ Night □ Online □ Medical Billing & Coding □ Online □ S RNA □ Day □ Online □ IV Certification □ Medical Billing Specialist □ Online □ CMAA □ Online □ Non-Refundable Application Fee $ 3 5 .0 0 □ CCMA □ Day □ Night □ Online □ Ph lebo tomy Tech □ Day □ Night □ Dental Assistant □ Day □ Online □ Medical Scribe □ Online □ Behavior Health Technician □ Online □ Course / Program Start Date Student Demographics: First Nam e Middle Initial Last Nam e Preferred Name Maiden Name (If Applicable) Street Address Email City State Zip Code Phone Number Date of Birth ( MM/ DD / YYYY) Social Security Number ( 0 0 0-0 0-0 0 0 0 ) Driver’s License Number State Expiration In order to comply w ith certain recordkeeping and reporting requirements, EMTP invites students to identify their ethnicity and race. We do not utilize this information to determ ine adm ission to our school. Are you Hispanic or Latino? □ Yes, I am Hispanic or Latino □ No, I am NOT Hispanic or Latino What is your race? □ Am Indian (American Indian or Alaskan Native) □ Asian □ Black □ Hawaiian (Native Hawaiian or other Pacific Islander) □ White Emergency Information: Emergency Contact Name Relationship Phone Number( s ) Address City State Major Medical Conditions / Allergies likely to cause em ergencies. I authorize EMTP to contact the above person in the event of an emergency and release information necessary to provide for my well-being. I attest that I am free from addiction to alcohol or any other controlled substance. I understand that if suspected of substance abuse that I will be subject to drug and/ or alcohol testing at my expense. To the best of my knowledge, I do not know of any physical and/ or mental condition that would impair and/ or interfere with my ability to perform the required duties of a healthcare professional. In the event that I am suspected of having a condition that impairs my ability to perform the required duties that I may be required to submit written approval from a licensed physician. Student Signature Date Educational Background: High School Nam e City State High School Graduation Date GED Certification Date Other Training / Education: Are you using this program for entrance into another educational program ? □ Yes □ No Do you intend to simultaneously enroll at Asbury University? □ Yes □ No Employment Background: Employment Status : □Full-Time □Part-Time □Unemployed □Full-Time Student at Other School Current Employer Supervisor’s Name Work Phone Number Employer Address City State Zip Other Experience: Type of Desired Employm ent ( check all that apply) : □Full-Time □Part-Time □Either. Criminal Background: Have you ever been convicted of a felony, pled guilty to a felony, entered into an Alford plea to a felony, or participated in a diversion program for a felony? □ Yes □ No By submitting this application, I am giving EMTP permission to submit my information to the Commonwealth of Kentucky in order to perform a background check for the purpose of program acceptance and certification eligibility. I understand that failure to accurately provide the information requested may result in my prosecution under KRS 523.10 0 . Page 2 of 6 Student Signature Date Hepatitis B Vaccination Statement of Understanding: I understand that due to my possible exposure to blood or other potentially infectious materials during my healthcare training and as an employee of the healthcare field I may be at risk of acquiring the Hepatitis B Virus (HBV) . I have been given the opportunity to be vaccinated for HBVat my own expense. I understand that by declining this vaccination I will continue to be at risk of acquiring HBV which is a potentially lifethreatening

FAQs

How does the applicant choose a desired course or program?

Applicants are asked to complete student demographics, including whether they are Hispanic or Latino and their race category, and to provide personal identification fields such as address, contact details, date of birth, and driver’s license information.

What authorizations and statements does the student provide?

The application grants EMTP permission to submit information to the Commonwealth of Kentucky for a background check and includes acknowledgements related to compliance and required testing if substance abuse is suspected. The student also attests to the ability to perform required duties to the best of their knowledge.

What is required regarding Hepatitis B vaccination status?

Applicants review the Hepatitis B vaccination statement and initial the line that matches their current vaccination status or decision. The form explains that declining vaccination maintains risk and that the student may receive the series later at their own expense while providing EMTP with required vaccination records by the student-manual deadline.

Oct 3, 2026

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