Emergency Medical Technician

Transcription

1 Emergency Medical Technician Admission Requirements EMERGENCY MEDICAL TECHNICAL IMPORTANT: PLEASE READ CAREFULLY

2 Classes are held on Tuesday and Thursday nights from 5:00 p.m. until 9:00 p.m. All classes are held at the campus located in Mayhew, Mississippi; classes are limited to 30 students. In order to be considered for admission to this class, you must have the following information on file in the Counseling Office (Golden Triangle Campus) before you can register for classes. Deadlines are: Spring---December 1 st Fall August 1st Admission Requirements: 1. A completed application to EMCC Golden Triangle. 2. A copy of your valid driver s license showing you to be 18 years old before the beginning date of the EMT class. 3. An official transcript from your high school showing date of graduation or official GED transcript showing high school equivalency. 4. A minimum scale score of 77 on the Reading section of the COMPASS or a minimum ACT composite of 16 if taken after October 1989 or composite of 12 if taken before A valid CPR certification card (Heath Care Provider Level). 6. A physical examination showing you to be physically fit per physician (dated within six months prior to beginning date of the EMT class) with a current shot record (report should include dates of Tetanus (dated within 10 years) and childhood vaccines ). Proof of Tuberculin test (dated within 1 year) and proof of starting the Hepatitis B vaccinations prior to clinical and ambulance rotations OR a declination form regarding the Tuberculin test and Hepatitis B vaccinations must be in the your admission file. The COMPASS test will be administered based on the enclosed schedule at a cost of $20. The ACT test will also be administered based on the enclosed schedule at a cost of $35. Testing for the COMPASS and the ACT could take up to 4 hours. In order to reserve a seat for the Compass and ACT test, you must pay in the business office and sign up for the next available test that fits your schedule.

3 The EMT program has been approved for a credit of 8 semester hours. Tuition is $ , registration is $65.00, liability insurance is $76.80, program fee is $100.00, books are approximately $141.00, and parking decal is $15.00 for a total of $ All fees are due upon registration/first night of class. There is no financial aid available for EMT classes. *NOTE: ALL COSTS ARE APPROXIMATE AND SUBJECT TO CHANGE. COSTS ARE BASED ON EXPENSES. Felony convictions may impact your ability to complete the program. For additional information, please contact John McBryde at before registering for this program. If you have any questions, please contact the counselor at Name of Student: Date:

4 I. Physical: TO BE COMPLETED BY A PHYSICIAN Physician s Name: Address: Phone: Physical Examination: Vital Signs: BP: Pulse: Resp.: Height: Weight: General Appearance Neck/Head Nutritional Status Eyes Chest Peripheral Vascular Visual Acuity Lungs Musculoskeletal Ears Heart Neurological Auditory Acuity Abdomen Skin Nose/Throat Breast Axillae Current Treatment: In your opinion, is there any health problem which would interfere with this individual s ability to pursue a program of study and/or a career in an allied health program? Remarks/Special Recommendations: Date of Examination: _ Signed:, M.D. ANNUAL DIAGNOSTIC TEST/RESULTS Mantoux Turberuculin Skin Test (IF NEGATIVE, NO CHEST X RAY REQUIRED) Date: Result: Signed, M.D. or R.N. (Or) Negative Chest X Ray Date Previous physical transfer statement: Has student been under the care of a physician or been hospitalized since this physical was completed? Yes: No: Signed, M.D. or R.N. Name of Student: Date: II. Physical: TO BE COMPLETED BY A PHYSICIAN The following information must be certified by the physician or Health Department:

5 Immunizations must be current with dates listed. Date: Diptheria/Tetanus (must be dated within 10 years) Polio (date of SOS ) Mumps Vaccine OR Previous History of the Disease Measles (Rubeola) Vaccine (Once since 1967) OR Previous History of the Disease German Measles (Rubella) Vaccine (Adolescence or Adulthood) OR Positive Titer Hepatitis B Vaccination Dates 1 st Dose 2 nd Dose 3 rd Dose Proof of immunizations and skin test is required (either a copy of the official report/certificate or information signed by the physician). Physician s Name:, M.D. OR Health Department For Office Use Only Hepatitis Immunization Coordinators Initials

6 FALSIFICATION OF INFORMATION IS A BASIS FOR DENYING ADMISSION OR FOR IMMEDIATE TERMINATION OF ENROLLMENT. Student Health Record Student (Print ) Date of Birth Last First Middle Parent/Guardian / Spouse Student Home Phone Home Address City State Zip Have you ever had or do you now have any of the following? (Please check to the right of each item.) Arthritis Asthma Back Problems Chest Pain Chronic Cough Diabetes Digestive Disturbances Diptheria Ear/Nose/Throat Problems Excessive Bleeding Excessive Weight Loss Eye Problems Foot Problems Frequent Colds Frequent or Severe Headaches German Measles Hay Fever Hearing Difficulties Heart Disease Yes No Yes No Hernia High Blood Pressure Jaundice Kidney Or Bladder Problems Measles Menstrual Disorders Mumps Rheumatic Fever Scarlet Fever Seizure Disorders, Epilepsy Shortness of Breath Skin Disorders Speech Difficulties Swollen or Painful Joints Tooth or Gum Problems Tuberculosis Ulcer Varicose Veins Venereal Disease Do you have any food or drug allergies? List them. What medications are you currently taking? Have you been or are you in drug or alcohol rehabilitation? Do you smoke? Have you had any surgical operations? List them. Have you had any accidents or injuries? List them. Do you have any other health problems? List them. I certify that I have reviewed the information that I have supplied and that it is true and complete to the best of my knowledge. Date: Signed (Student s Signature) Student Date

7 Pulmonary History (May be submitted in lieu of a chest X ray in the event of a previous positive TB test.) 1. Do you have a chronic cough? Yes No 2. Do you Smoke? Yes No If yes, how much? 3. Have you lost weight recently? Yes No If yes, how much? Were you trying to lose weight? Yes No 4. Have you coughed up blood? Yes No If yes, how much? 5. Have you noticed any shortness of breath? Yes No 6. Have you had any night sweats? Yes No 7. Have you been around anyone who has TB? Yes No 8. Have you had a TB test? Yes No A. Was it: Positive or Negative? B. When was it first Positive? C. What medication did you receive and for how long? MISSISSIPPI GED TRANSCRIPT REQUEST

8 (Please Print.) NAME (Name at the time of test) Date of Birth Month Day Year Social Security No. Current Name Current Mailing Address P.O. Box OR Street Address City State Zip Code Telephone No. ( ) Area Code Date GED tests were taken Did you pass the tests and receive a diploma? Name and location of the GED Testing Center GED Diploma No. Date Issued (If known) (If known) PLEASE PRINT NAME AND ADDRESS TO WHICH GED TRANSCRIPT SHOULD BE MAILED: East Mississippi Community College Golden Triangle Campus Office of Admissions P.O. Box 100 Mayhew, MS PLEASE CHECK: $5.00 is enclosed for transcript $5.00 is enclosed for diploma $10.00 is enclosed for both I hereby authorize the State GED Administrator to release my GED transcript to the address listed above. Signature (Signature is required to mail transcript) Date THERE IS A $5.00 CHARGE FOR A COPY OF YOUR TRANSCRIPT. PAYMENT MUST BE MADE BY CASHIER CHECK, CERTIFIED CHECK, OR MONEY ORDER. PLEASE MAKE IT PAYABLE TO THE SBCJC. THERE IS AN ADDITIONAL CHARGE OF $5.00 IF YOU REQUEST ANOTHER DIPLOMA. PAYMENT MUST BE MADE CASHIER CHECK, CERTIFIED CHECK, OR MONEY ORDER. PLEASE MAKE IT PAYABLE TO THE SBCJC. PERSONAL CHECK OR CASH WILL NOT BE ACCEPTED. MAIL THIS FORM TO: State Board for Community and Junior Colleges State GED Office 3825 Ridgewood Road Jackson, Mississippi 39211