EMT Student Registration Form Spring 2016

All Registrations must be taken or mailed to our Halford Hall location. Students will not be permitted to enter the course on Angel YOU WILL BE PUT ...
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All Registrations must be taken or mailed to our Halford Hall location. Students will not be permitted to enter the course on Angel

YOU WILL BE PUT ON A WAITING LIST until the following documents are received: (1. DOH 3312 form – Verification of Membership; 2. Registration form and 3. Applicant Response Form)

EMT Student Registration Form – Spring 2016 Name: ________________________________________________ Last 4 of SSN: XXX-XX-_ _ _ _ DOB: ____/____/______ Last First MI Maiden/ Previous Name (if any) ____________________________ E-mail Address: ______________________________ Phone (home): _____________________ (work): _______________________ (cell): _____________________________ Address: _______________________________ City, ________________________ State: ____________ Zip: _________ Are you a New York State Resident? __ Yes __ No Have you ever taken a course offered by SUNY Canton? __ Yes __ No If yes, year & semester attended: ________________ Are you enrolled in a SUNY Canton degree program? __ Yes __ No Have you ever attended another college? __ Yes __ No If yes, What College? ___________________________________ High school attended: ______________________________________ Are you NOW a high school student? __ Yes __ No Year of high school graduation or GED Awarded: ________________ __ Married __ Single __Veteran __ Male __ Female Have you ever been convicted of a felony? __ Yes __ No Have you ever been dismissed from a college for disciplinary reasons? __ Yes __ No Ethnic Code (Please Circle) (Ethnic code information is optional) Asian / Pacific Islander American Indian / Alaskan Black Non – Hispanic White / Non – Hispanic Non – Resident Alien

Hispanic

Other: ________________

Rescue Squad / Fire Dept. ______________________________________________ Phone: (_____)________--________

Please indicate the course you are applying for by checking the appropriate box: COURSE Basic EMT Original – SUNY Canton

COURSE NUMBER Not Available At This Time

COURSE COST $775 (non-agency applicant)

Deadline for all registrations is December 28th 2015 ***ALL REGISTARTIONS MUST BE POSTMARKED FOR FAXED BY THE ABOVE DATE TO BE CONSIDERED*** Mail to: SUNY Canton EMT Program, 34 Cornell Drive, Halford Hall, Canton, NY 13617 OR Fax to: (315) 386-7961 / Scan and Email to [email protected] If you have any questions please contact us at (315) 386-7973

NEW YORK STATE DEPARTMENT OF HEALTH

Verification of Membership in a NYS EMS Agency

Bureau of Emergency Medical Services

Please print legibly in capital letters or type. Put one letter or number in each box. This form must be completed and returned to the Course Sponsor prior to the completion of the course. Course Number

(Please retain this number for future reference)

Check if this application is for:

Original Certification

Recertification

(If you are recertifying you must include your NYS EMS I.D. Number)

EMS Identification Number (If you have one) Only write your NYS EMS number in this space

Applicant’s Last Name

Applicant’s First Name and M.I

If you belong to an EMS agency, please indicate the agency code in the box(es) below. Primary EMS Agency

Secondary EMS Agency

Primary Agency Name

Primary Agency Captain, Chief, or other agency official signing the affirmation on this form Last Name

NYS EMS Identification Number (If you have one)

First Name and M.I.

Official’s Agency Title

Personal Affirmation

Read Carefully Before Signing

I, as an official representative of the primary NYS EMS agency listed on this form, affirm that the applicant named on this form is a member of the primary NYS EMS service. I further understand that offering or providing false information on this document may constitute a crime

under the penal law and may subject any certification to revocation or other Department action. I, as the applicant, hereby certify that all of the information contained in this application is true and correct and that the signature below is mine as applicant. I further understand that offering or providing false information on this document may constitute a crime under the penal law and may subject any certification to revocation or other Department action.

(Agency Official’s Signature)

(Date)

(Applicant’s Signature)

(Date)

DOH-3312 (5/07)



EMT Program Applicant Check List- Fall 2015 Semester EMT Basic Original and Refresher Classes o 1. SUNY Canton Registration Form – Fall 2015 o 2. Verification of Membership in an EMS Agency (DOH-3312) o (Note: This must be signed by the member AND the agency representative.) o Applicants who are not affiliated with a New York State agency such as a fire department Ambulance service, registered first responder department, or an independent rescue squad will be required to pay a tuition cost of $775 as there is no state reimbursement of funding for non-affiliated members. This payment is to be paid in full by October 1 2015. o 3. Basic Refresher students only: Basic refresher students MUST include a copy of his or her EMT card. The state requires this to show proof of taking a basic original class.

Advanced EMT and Critical Care Original Classes o 1. In addition to items 1 and 2, any student registering for the AEMT or Critical Care MUST include a copy of his/her current EMT card. This card cannot expire before the scheduled state written examination date. o 2. CC Refresher students only: Critical Care refresher students MUST include a copy of his or her Critical Care Card. The state requires this to show proof of taking an original Critical Care class.

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Medical Information for Original Students o 1. Although medical information is not needed when riding in an ambulance, in the past students have waited until the last couple of weeks then find they cannot get the ride time completed. Now they need to do Emergency Room clinicals and their medical records are incomplete. Therefore, we request that copies of all the information outlined on the Health and Physical Requirements be included with the registration application. If not available, please obtain and submit this information as soon as possible. A health physical and two (2) PPD/TB test results must be current within the past year. This information is required by the hospitals in order to do clinical hours at their facility. Also, the hospitals have updated their medical requirements to include dates of proof of Varicella (chicken pox) vaccination or a positive titer for antibodies and the date of the applicant’s last tetanus shot.

All Applicants o 1. All registrants must sign below and include this form with registration materials. o 2. I hereby grant permission to SUNY Canton to withdraw me from the course for failure to

attend classes OR for not being able to complete the course as scheduled. _________________________/___________________________________/____________________ Print Name Signature Date (Please submit both copies)

Mail this signed Applicant Response Form, (along with ALL required documentation) to:

SUNY Canton · 34 Cornell Drive, EMT Program – Wicks hall 027, Canton, NY 13617 or fax to (315) 379-3979

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SUNY Canton EMT Program Fall 2015 EMS Course Information Full course information can be found at www.canton.edu/emt Course Name EMT Original

Instructor Donald Thompson





Location Nevaldine South Room 133

Dates 8/24/15 – 12/17/15

Days Times Monday, Wednesday, 6:30pm - 9:30pm (Mon,Wed) 9am-noon, 1-4 pm (Sat) Some Saturdays

Course Name

Copy of EMT Card

Basic EMT Original

N/A



Hours of Mandatory ER / Hospital Time

Hours of NYS EMT Practical NYS EMS Final Mandatory Exam Date Written Exam Date Ambulance Time 05/09/2016 Combined 10 hours 05/11/2016 05/19/2016 (If all ride time, minimum of 6 calls) ½ of the class each night

*For Refresher courses, an expired card is also acceptable if you have let your card run out. Otherwise, please submit a copy of your current card with your registration materials. **All students taking an original Advanced or Critical Care course must possess a current New York State EMT certification that will be valid throughout the entire Advanced or CC course. A copy of the EMT card is to be submitted along with your registration materials. If you card is going to expire prior to the State Exams for that course you must take a refresher course first.

HEALTH AND MEDICAL LIABILITY REQUIREMENTS *Required for all applicants taking Basic EMT Original OR Critical Care EMT Original* A copy of the following medical records and the department’s medical liability insurance or personal medical liability insurance proof should be submitted along with the registration material.

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*Requirements for All Original Students* ACCEPTABLE PROOF Doctor, clinic, military, school, employment, or fire department/rescue squad physical and/or immunization records.

MEDICAL LIABILITY INSURANCE A current copy of your Department’s liability insurance or a copy of your personal liability insurance.

PHYSICAL Copy of a physical exam completed within the last year. A health reassessment form can be completed if a physical was done 1-3 years ago.

PPD Mantoux (TB) Dates and signatures of 2 negative results within last 12 months or a negative chest x-ray within 5 years for anyone with a history of a positive PPD test result.

o o o o

RUBEOLA (Red Measles) Proof of one of the following is attached: 1. Dates of 2 live Rubeola immunizations; both given after 1957 and on or after the 1st birthday. These would be MMR vaccinations. 2. Dated and signed results of a positive titer or a copy of the lab results. Note: Exempt if born before January 1, 1957.

o

RUBELLA (German Measles) Proof of one of the following is attached: 1. Date of 1 live Rubella immunization given on or after the first birthday. These would be MMR vaccinations. 2. Dated and signed results of a positive titer or a copy of the lab results.

o

MUMPS (optional) Proof of one of the following is attached: 1. Date of 1 live mumps immunization given on or after the first birthday. 2. Dated and signed results of a positive titer or a copy of the lab results. 3. MMR is the same as the above three individual immunizations HEPATITIS B One of the following must be documented: oDates of the completed series of all 3 immunizations. oDate of first immunization showing series is in progress. oDated and signed results of a positive titer or a copy of the lab results. oSigned waiver refusing the immunizations.

VARICELLA (Chickenpox) The hospitals are requiring dates of two chickenpox vaccinations or proof of a positive titer for antibodies. A note from your doctor stating you have had them is no longer acceptable. Tetanus Shot: Tetanus is good for 10 years. It is suggested that if someone’s has

o

o

o

not had a vaccination in the last 2-3 years that they receive the booster of Tdap due to pertussis outbreak that has occurred in the last few years

o

FLU VACCINATION The hospitals require a flu vaccine for ALL students.

o

_______________________ Applicant’s Signature

/ _________/________ Date

_______ Print Name

_

It is the sole responsibility of each student to meet health and medical liability requirements.

If needed, this form is for your use SUNY Canton Health History, Physical Exam Immunization Form SUNY Canton, EMT Program – FAX: (315) 379-3979 Print Name:

Social Security #:

û û û - û û - ___ ___ ___ ___Date of Birth________________

Address_______________________________________City_______________________________State__________________Zip Code___________ Telephone Number: Home (

)

Cell Phone: (

)

PART I: IMMUNIZATION/MENINGITIS REQUIREMENTS: IMMUNIZATIONS Required by Public Health Law 2165: Measles Mumps and Rubella: MUST BE GIVEN AFTER Jan. 1, 1969 and ON OR AFTER THE first BIRTHDAY. Doses must be at least 28 days apart.

MMR: 1st____/____/____

Date: _________________ Result in mm ____________________ Signature of person reading results_______________________ If positive Chest x-ray Date:_______ _________ Result:_______ _ _

2nd____/____/____

Mo Day Yr

Mo Day Yr

OR Measles (Rubeola) 2 doses: 1st____/____/____

# 1 Tb Mantoux: Required for all original EMT students. A second PPD Mantoux is required unless the two tests are for two consecutive years. (2012 & 2013)

#2 Tb Mantoux: (2nd PPD must be at least one week after the first PPD )

2nd____/____/____

Mo Day Yr

Mo Day Yr

Rubella____/____/____

Mumps____/____/____

Mo Day Yr

Mo Day Yr

A titer proving immunity for each of the above is an acceptable alternative to receiving the immunizations. A copy of the results is required. Please attach to this form.

Date: __________________ Result in mm __________________ Signature of person reading results_______________________ If positive Chest x-ray Date:_______ _________ Result:_______ _ _ HEPATITIS B VACCINE: If completed list dates of each dose:

2. Two Varicella Vaccinations or proof of titer: st nd 1 ____/____/___ 2 ____/____/____ titer ___/____/___

Dose #1____________ Dose #2____________ Dose #3____________

Date of last Flu shot________________ Date of last Tetanus Shot: _____________________________

PART II: PHYSICAL EXAM: (name) AGE:

SEX:

B/P

VISION FAR: R: 20/__________________

PHYSICAL EXAM

WEIGHT:

L: 20/ __________________

NORMAL

ABNORMAL

HEIGHT __________

□ without correction

□ with correction

COMMENTS

1. GENERAL APPEARANCE 2. SKIN 3. HEENT 4. NECK 5. LUNGS 6. HEART 7. ABDOMEN 8. MUSCULOSKELATAL 9. PSYCHIATRIC

To the best of my knowledge this student (is/is not) free from physical or mental impairments including habituation or addition to depressants, stimulants, narcotics, alcohol or other behavior altering substances which might interfere with the performance of his/her duties or would impose a potential risk to patients or personnel. Examining Health Care Provider (MD, DO, NP, PA) (Signed) Print Name

Phone: _________________________ Date ________________

RETURN FORM TO: SUNY Canton, EMT Program, Wicks hall 027, 34 Cornell Drive, Canton NY 13617

TEXTBOOK INFORMATION

To:

All Rescue Squads and Fire Departments

Subject: Textbook Pre-Hospital Emergency Care by Brady, 12th edition Books may be ordered on line at www.bradybooks.com. or Another avenue that may be considered is going to Amazon.com and search for EMT books. All the options for purchase of the 12th edition will be listed there. Any questions, please feel free to contact me either by email or at the office number listed below. Sincerely, Ann Smith Ann Smith EMT Program Coordinator Office: 315-386-7973 Fax: 315-386-7961 [email protected]