Student Interest Survey

First Name *

Last Name *

Email address *

Current Grade Level *

Are you interest in the medical field *

Yes

No

Maybe

Have you or would you consider a career as an EMT or Paramedic? *

Yes

No

Maybe

Would you be willing to spend time after school training to be an EMT? *

Yes

No

Maybe

Would you be willing to spend 4 hours every other Sunday for hands on lab? *

Yes

No

Maybe

How large of a factor is cost in your decision making? *

Small

Minor

Major

May we contact you if we develop a junior EMS program? *

Yes

No

reCAPTCHA Checkbox *