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The form requests demographics, education and employment background, criminal history declaration, and signatures authorizing EMTP to conduct required background checks. 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We do not utilize this information to determ ine adm ission to our  \nschool.  \nAre 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  \n□ Hawaiian (Native Hawaiian or other Pacific Islander) □ White  \nEmergency Information:  \nEmergency Contact Name  \nRelationship  \nPhone Number( s )  \nAddress City State  \nMajor Medical Conditions / Allergies likely to cause em ergencies.  \nI 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.  \nStudent Signature Date  \nEducational Background:  \nHigh School Nam e City State  \nHigh School Graduation Date GED Certification Date  \nOther Training / Education:  \nAre you using this program for entrance into another educational program ? □ Yes □ No Do you intend to simultaneously enroll at Asbury University? □ Yes □ No  \nEmployment Background:  \nEmployment Status : □Full-Time □Part-Time □Unemployed □Full-Time Student at Other School  \nCurrent Employer Supervisor’s Name Work Phone Number  \nEmployer Address City State Zip  \nOther Experience:  \nType of Desired Employm ent ( check all that apply) : □Full-Time □Part-Time □Either.  \nCriminal Background:  \nHave 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?  \n□ Yes □ No  \nBy 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 .  \nPage 2 of 6  \nStudent Signature Date  \nHepatitis B Vaccination Statement of Understanding:  \nI 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 ","cbCaidQpoQPTuxMQ","https://ap.wps.com/l/cbCaidQpoQPTuxMQ","pdf",144273,"English","# Desired Course/Program\n# Student Demographics\n# Emergency Information\n# Educational Background\n# Other Training / Education\n# Employment Background\n# Other Experience\n# Criminal Background\n# Hepatitis B Vaccination Statement of Understanding\n# Program / Course Tuition and Fees","[{\"question\":\"How does the applicant choose a desired course or program?\",\"answer\":\"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.\"},{\"question\":\"What authorizations and statements does the student provide?\",\"answer\":\"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.\"},{\"question\":\"What is required regarding Hepatitis B vaccination status?\",\"answer\":\"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.\"}]","Allied Health Application - Desired Course/Program Selection - Student Demographics & Authorization | PDF",1791044888,15]