Emergency Medical Services (EMS) Academy accepting applications, Questionaire
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SUBMIT APPLICATIONS AND ADDITIONAL MATERIALS ONLINE:
Office of Human Resources: 651-266-6500
24-hour Recorded Jobline: 651-266-6502
Exam Number# 12-09011YJC
EMERGENCY MEDICAL SERVICES (EMS) ACADEMY
Emergency Medical Services (EMS) Academy Supplemental Questionnaire
* 1. Enter your full middle name. If you do not have one, please enter N/A.
* 2. Sex
3. Cell Phone Number beginning with area code - xxx-xxx-xxxx
* 4. Home Phone Number beginning with area code - xxx-xxx-xxxx
* 5. Social Security Number - xxx-xx-xxxx
* 6. Date of Birth - MM/DD/YYYY
* 7. Current Age
* 8. Citizenship
Non-citizen/Eligible to Work
* 9. If selected Non-citizen/eligible option above, provide I-94 number below. I-94 number or 'N/A' if US Citizen.
* 10. School currently attending
Junior College, College, or University
St. Paul Public School
Not in School
* 11. Grade
* 12. Student ID#. If not in school, enter N/A.
* 13. Will you be attending school during the Spring Semester of 2013 (January-May of 2013)?
I Don't Know
* 14. Are you currently employed (includes family businesses)?
15. If currently employed, where do you work?
* 16. How were you referred to the EMS academy?
Social Service Agency
Place of Worship
Friend or Relative
* 17. Do you have a temporary or permanent disability? Disability Status: Disability/Disabled is defined as: (1) Has physical, sensory or mental impairment (condition which significantly limits one or more life activities); or (2) has a record of such impairment (condition); or (3) is regarded as having such an impairment (condition)
18. If answered Yes to Question 17, how would you describe the disability? (Check all that apply)
19. If selected Other for Question 18, please explain.
20. Has this disability been documented by a professional? If yes, verifying documentation will be required.
* 21. INCOME AFFIDAVIT THE APPLICANT'S PARENT/GUARDIAN OR 18+ APPLICANT MUST COMPLETE QUESTIONS 21 THROUGH 28. PLEASE READ THE QUESTIONS VERY CAREFULLY. What is the number of adults and children living in your household (including applicant)?
* 22. Enter the total household income expected in the next 12 months for ALL household members
reported in Question 21. This question is mandatory. N/A is NOT an acceptable answer.
Applicants who do not complete this question correctly will be considered ineligible.
Sources of income include: * gross wages and tips * social security * pensions * alimony *
child support * other periodic income such as rental income and regularly paid insurance
premiums. You may be asked to provide documentation of your household income upon
request. My household will earn $ __________ dollars in 2013:
* 23. Is your household female-headed? (for statistical purposes)
* 24. Is your family Hispanic? (for statistical purposes)
* 25. Check the race(s) appropriate for your family: (for statistical purposes)
Native Hawaiian or Other Pacific Islander
American Indian/Alaskan Native
* 26. Is the applicant a systems involved youth or 18+ in foster care, juvenile offender, etc.? (for statistical purposes)
* 27. Are you or your family receiving public assistance? (for statistical purposes only)
* 28. Certification of parent/guardian or 18+ Applicant. WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make false statements or misrepresentations to any Department or Agency of the U.S. as to matters within its jurisdiction. This program is being assisted with Community Development Block Grant (CDBG) funds provided through the City of Saint Paul, which it receives from the U.S. Department of Housing and Urban Development (HUD). A requirement of this assistance is that we collect income data of persons who apply for assistance. This information will not be disclosed or released by this office without your consent, except to the City of Saint Paul and to HUD, and except as required or permitted by law. I have read the above statement and agree to make my financial records available to the City of Saint Paul or HUD for verification of the above information. I certify that the information above is, to the best of my knowledge and belief, a true, correct, and complete statement of my financial condition as of the date stated herein.
* 29. Tell Us About Yourself in Questions 29-31. Please write complete sentences and be thorough in your response to each question. Why are you applying for the EMS Academy?
* 30. What type of job or skills would you like to gain from attending the EMS Academy?
* 31. What special qualities would you bring to the EMS Academy?
* 32. In what organized activities do you currently participate? (Check all that apply)
National Honors Society
Other School Club(s)
Other Organized Activity
* 33. For the parent or 18+ applicant: (Parent) Does your child have a medical condition that may be life threatening? (18+ applicant) Do you have a medical condition that may be life threatening?
34. If answered Yes to Question 33, please describe the medical condition.
* 35. In case of emergency, provide the full name of the person to be contacted.
* 36. What is the relationship of the contact person entered for Question 35 to the applicant?
* 37. Home phone number, including area code, of emergency contact person.
38. Work phone number, including area code, of emergency contact person.
39. Cell phone number, including area code, of emergency contact person.
* Required Question