EMERGENCY MEDICAL TECHNICIAN/PARAMEDIC CERTIFICATE LEARNING PROGRAM #133

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1 SUPPLEMENTAL APPLICATION FOR ADMISSION Fall 2016 r Spring 2017 ENTRY APPLICATION INFORMATION and INSTRUCTIONS Applicatin Deadline: Fr Fall 2016 Deadline is April 15, 2016 Fr Spring 2017 Deadline is Octber 15, 2016 Submit Emergency Medical Technician/Paramedic Prgram Supplemental Applicatin, the $25 applicatin fee and all ther required admissins dcuments t: Hward Cmmunity Cllege Office f Admissins and Advising RCF Building-242, Little Patuxent Parkway Clumbia, MD QUESTIONS: Telephne: Fax: Admissins: CORRESPONDENCE: Crrespndence will be sent t yur HCC accunt if yu are currently enrlled in cursewrk at Hward Cmmunity Cllege. If yu are nt currently enrlled in cursewrk at Hward Cmmunity Cllege, please ensure the address prvided n the supplemental applicatin is current and checked ften as this will be the fficial mde f cmmunicatin thrughut the applicatin prcess. ADDITIONAL ADMISSIONS REQUIREMENTS: HCC General Applicatin fr Admissin ($25 applicatin fee) with Emergency Medical Technician/Paramedic (#133) declared as Learning Prgram Cde Official Transcript Evaluatin Request Frm submitted fr prir learning credit (if applicable) Official academic transcripts frm each cllege/university submitted fr prir learning credit (if applicable) EMT Certificatin: Students are required t hld an active Maryland r Natinal Registry EMT Certificatin; all students are required t present an fficial EMT card/certificatin at the time f applicatin t the Office f Admissin and Advising (RCF-242) Overall HCC GPA f 2.0 r higher Accepted applicants must be 18 years f age r lder at the time f matriculatin Official (sealed) High Schl r GED Transcript indicating cmpletin f high schl RESIDENCY: Applicants wh reside in Hward Cunty fr a minimum f 90 days prir t the applicatin deadline will be given pririty in the selectin prcess. Hward Cunty applicants must submit ne f the fllwing dcuments frm each f the lists belw fr a ttal f tw. The Cllege reserves the right t request additinal infrmatin and dcumentatin as necessary. Select ne frm this list: Valid Maryland driver s license MVA issued change f address card Valid state issued ID Vter s registratin card Rental agreement/deed/lease Select ne frm this list:* Utility bill: gas, electric, phne, cable, water Hward cunty tax bill Statement frm bank, credit card r insurance cmpany Pay stub with current address *Must be dated within three mnths f submitting applicatin INTERNATIONAL (F1) STUDENTS: Clinical curses cannt be guaranteed, therefre, internatinal (F1) students may nt enrll in the Emergency Medical Technician/Paramedic area f study. PRIOR LEARNING CREDIT: If yu expect t transfer credit, all academic cursewrk taken utside f HCC frm an accredited cllege/university shuld be evaluated by submitting fficial transcripts in sealed envelpes frm each cllege/university, the Official Transcript Evaluatin Request Frm (als available in the Office f Admissins & Advising) and a $15 prcessing fee. Academic cursewrk cmpleted utside f the United States must first be evaluated, curse-by-curse, fr transfer by a natinally accredited transcript evaluatin service accepted by HCC, (list available in the Office f Admissins & Advising) and then sent t Hward Cmmunity Cllege, Office f Admissins & Advising. Please see reverse side

2 APPLICATION INFORMATION and INSTRUCTIONS Cntinued ADMISSION SELECTION: Qualified students will be selected n a rlling basis. Once all seats in the class have been assigned, the remaining qualified students will be placed n a waitlist. If an accepted student declines his/her ffer f admissin r fails t meet the prvisins f their acceptance, as utlined in their letter f acceptance, the next eligible student n the waitlist will be ntified fr placement in the class. NON-REFUNDABLE $300 DEPOSIT: If admitted, a nn-refundable $300 depsit will be required frm accepted students t hld their seat in the class and will be applied t their Fall 2016 r Spring 2017 tuitin. REQUIRED DOCUMENTATION: If admitted, Health Frms with immunizatin and titer certificatins and CPR Certificatin will be required in rder t ensure the safety f patients in the clinical setting. PLEASE NOTE: If admitted, a Drug Screening and Criminal Backgrund Check will be required prir t enrllment in any nursing/allied health clinical curse in rder t ensure the safety f patients in the clinical setting. Students wh d nt cmply with the drug screening and criminal backgrund check are ineligible fr placement in clinical agencies and therefre are nt able t prgress in the clinical nursing/allied health prgram. Students with a criminal backgrund r psitive drug screening may be unable t prgress in the clinical nursing/allied health prgram. It is the students respnsibility t knw whether they are eligible fr licensure by cnsulting directly with the Maryland Institute fr Emergency Medical Services System (MIEMSS) Cmpliance Officer. If students have a criminal backgrund, it is the students respnsibility t explre whether the backgrund will prhibit them frm being licensed and emplyed in the health care industry. HCC faculty and staff are NOT able t prvide legal advice. If yu have any questins abut yur existing criminal backgrund, yu may wish t discuss this with legal cunsel. ACCREDITATION: The HCC Emergency Medical Technician Prgram is accredited thrugh the Cmmissin n Accreditatin f Allied Health Educatin Prgrams (www.caahep.rg) upn the recmmendatin f the Cmmittee n Accreditatin f Educatinal Prgrams fr the Emergency Medical Services Prfessins (CAEMSP), and apprved as a Maryland EMS Educatinal Prgram by the Maryland Emergency Medical Services Bard (MEMSB) upn the recmmendatin f the Maryland Institute fr Emergency Medical Services Systems (MIEMSS). Applicatins must be cmpleted in their entirety. Incmplete applicatins may nt be cnsidered.

3 SUPPLEMENTAL APPLICATION FOR ADMISSION FALL 2016 r SPRING 2017 ENTRY APPLICANT INFORMATION PRINT NEATLY AND COMPLETE FORM IN ITS ENTIRETY Please indicate the term yu are applying: Fall 2016: Spring 2017: HCC Student ID Number: Legal Cunty f Residence: Applicant s Full Name: first middle last Address: street address city state zip cde Telephne: Are yu a U.S. Citizen? Yes N If n, please indicate Immigratin/Visa Status: Please indicate if yu have a prir degree: Assciate Bachelr Masters Dctrate Medical Dctr If s, in what field? What academic institutin? Have yu ever been adjudicated guilty r cnvicted f a misdemeanr, felny, r ther crime, r ther crime nt shielded under the Maryland Secnd Chance Act? Yes N PRE- / CO-REQUISITE COURSES PREREQUISITE COURSES LIST ACADEMIC INSTITUTION/S DATE COMPLETED / COMPLETING MICROBIOLOGY (BIOL-107 r BIOL-200) GENERAL BIOLOGY (BIOL-101) 4 credits with lab (cmpleted with a C r higher) [10 year time limit] ANATOMY & PHYSIOLOGY I (BIOL-203) 4 credits with lab (cmpleted with a C r higher) [5 year time limit] ANATOMY & PHYSIOLOGY II (BIOL-204) 4 credits with lab (cmpleted with a C r higher) [5 year time limit] THE FOLLOWING COURSES MAY BE TAKEN AS PRE- OR CO-REQUISITE. PREFERENCE IN THE ADMISSIONS PROCESS IS GIVEN TO APPLICANTS WHO HAVE COMPLETED ALL PRE- AND CO-REQUISITES BY THE APPLICATION DEADLINE. DRUG CALCULATIONS (HEAL-105) 1 credit (cmpleted with a C r higher) Please see reverse side

4 SUPPLEMENTAL APPLICATION FOR ADMISSION Fall 2016 r Spring 2017 REQUIRED APPLICANT SIGNATURE Carefully review and initial each item listed belw and then please sign and date. I understand that I must be 18 years f age r lder in rder t matriculate. I understand that I may submit Supplemental Applicatins fr Admissin t mre than ne f the Nursing and Allied Health Prgrams. Hwever, nce I submit a $300 depsit t hld my seat in a prgram I will be required t withdraw all ther active Nursing and Allied Health Prgram applicatins. If nt already declared, I authrize the Office f Admissins and Advising t add #133 t my active learning prgrams. I understand that if admitted: I will be required t submit a nn-refundable $300 depsit alng with my Admissin Acceptance Frm by the given deadline. The depsit will hld a seat in the class and be applied t my Fall 2016 tuitin. If I d nt submit the depsit and frm by the given deadline, my admissin may be revked. I will be required t abide by cllege plicy as utlined in HCC s Catalg, Student Handbk, including the Student Cde f Cnduct, and the Emergency Medical Technician/Paramedic Student Handbk. I will be required t cmplete the requirements as utlined in my acceptance letter. I will be required t prvide the Student Health Frm with immunizatin and titer certificatins prir t enrllment in any clinical curse in rder t ensure the safety f patients in the clinical setting by the stated deadline r I will be dismissed frm the Prgram. I will be required t have a criminal backgrund check and drug screening prir t enrllment in any clinical curse in rder t ensure the safety f patients in the clinical setting by the stated deadline r I will be dismissed frm the Prgram. I will be required t btain Healthcare Prvider CPR Certificatin prir t enrllment in any clinical curse in rder t ensure the safety f patients in the clinical setting by the stated deadline r I will be dismissed frm the Prgram. I will be required t attend the mandatry New EMT Student Orientatin (date and time TBD). I will be assigned and expected t participate in ff-site clinical experiences and will be respnsible fr my wn transprtatin and parking fees. Sites may be lcated in r arund the state f Maryland. Clinical can be 24/7 and ccur utside f the designated class time. My signature cnfirms that the infrmatin I have prvided n this applicatin is truthful, that I have read all instructins carefully and that I agree with all stipulatins as utlined in the applicatin and admissin prcess. In additin I acknwledge that I have been given the pprtunity t btain the necessary infrmatin abut the Emergency Medical Technician/Paramedic Prgram including the admissins requirements, academic standards and essential functins. X Applicant Signature Date Hward Cmmunity Cllege is cmmitted t prviding equal pprtunity thrugh its educatinal prgrams, admissins and the many services it ffers t the cmmunity. It is the plicy f the cllege t abide by all applicable requirements f state and federal law s that n persn shall be discriminated against r therwise harassed n the basis f race, religin, disability, clr, gender, natinal rigin, age, plitical pinin, sexual rientatin, veteran status, genetic infrmatin r marital status.

5 The Cllege reserves the right t change unilaterally, withut ntificatin, any requirement, fee r prgram if it is deemed necessary.

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