Emergency Medical Responder (EMR) Application Package

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1 Emergency Medical Responder (EMR) Application Package Please ensure you read all of the instructions completely before submitting your application for an EMR Program. All sections of the application must be completed. All documents submitted become the property of ESA. If you are accepted into the program, original documents will not be returned to you; if you are not accepted, you may request the return of your application and ESA will keep a copy on fi le for a year. Please forward your complete application, full payment of fees, the completed checklist page and supporting documents to: Emergency Services Academy Ltd. 2 nd Floor, 161 Broadway Boulevard Sherwood Park AB T8H 2A8 Acceptance into an EMR Program You will be advised by of your acceptance into an EMR Program at ESA pending the receipt of a complete and acceptable application by ESA. Classes are capped at 24 students. If the class you apply for is fully registered, you will be offered a place in another class. The will include information about the EMR Orientation. If you have any further questions, please call ESA at Page A-1

2 Application Package - Part One Application Checklist - Include this page with your application. Applicant: Course Code: Surname First Name Middle Name ESA Use Student Checklist Have you completed the Waiver Form? Have you completed the EMR Application Form? Have you included the following with your application? See instructions on the following page for details. A. Proof of age B. Transcripts of Grade 12 High School Diploma/GED/equivalent or post secondary education or application as a Mature Student C. Basic Rescuer - CPR Level C or Health Care Provider D. Standard First Aid Certificate E. Do you require Special Academic Accommodations? Yes No If yes, you must submit the required documentation with your application package. Refer to our website: to ESA/Student Services/Academic Accommodation. ESA Use Only Date application received: Date application processed, fee paid: App v17 EMERGENCY SERVICES ACADEMY LTD Page A-2

3 Application Package - Part Two Instructions and Details for Completing the EMR Prerequisites A. Proof of age (minimum 18 years). A Driver s License is acceptable. B. Transcripts of Grade 12 High School Diploma/GED/equivalent or post secondary education, or acceptance as a mature student To apply as a mature student, you must be at least 21 years of age by the start date of the program and have completed Grade 12 Academic English with a minimum grade of 65 (or equivalent), and provide the following: Official transcripts of last formal high school or post-secondary education A personal letter from you that: Outlines life and work experience since the last period of full-time study Clearly summarizes your educational goals and your motivation to succeed in the Emergency Services Industry Acknowledges that you understand that future employers may require a high school diploma as a prerequisite to employment Any other relevant documents (e.g., results of any upgrading courses, SAT scores, etc.) C. Basic Rescuer - CPR Level C or Health Care Provider (Heart & Stroke Foundation, St. John s Ambulance or Red Cross). Dated within one year. D. Standard First Aid dated within the preceding three years. Pag e A-3

4 Application Package - Part Three Waiver Form I,, understand that in order to: apply for the EMT/PCP Program at ESA; register with a provincial regulatory body such as the Alberta College of Paramedics (ACP); work as an EMR, I will be required to: provide a clear security clearance; provide proof of all required immunizations; hold a class 4 driver s license; be registered with ACP or an equivalent body with a minimum EMR; maintain annual CPR certification. I may need to: provide a copy of a Grade 12 High School Diploma or GED; Please initial each of the above boxes to show that you understand each of the above requirements. Applicant s signature: Date: EMERGENCY SERVICES ACADEMY LTD Page A-4

5 Emergency Medical Responder (EMR) Application Package - Part Four Application Form Personal Information Surname Legal First Name Middle Name XS S M L XL XXL Birth Date (mm/dd/yyyy) Gender Tshirt Size How did you learn about ESA? Permanent Address (Street/Avenue/Box Number) City Province Postal Code Home Telephone Alternate Telephone Address - Mandatory Emergency Contact Person Relationship Telephone Registration Information Program: Start Date: Payment Are you applying for any funding for this program? Yes No If Yes, please provide details: Application and tuition fees are payable to Emergency Services Academy Ltd., and are subject to change. To confi rm current fees, please check our website or call (780) Include payment for total course fees for the EMR Program. Payment Amount $ Method of Payment: Cash Cheque/Money Order Debit VISA MasterCard American Express Credit Card Use: Card Number (will not be kept on fi le by ESA) Expiry Date Name of Cardholder: Cardholder s Signature: Declaration I hereby certify that all statements on this application are true and complete in all respects and no relevant information has been withheld. If accepted for the above course, I agree to comply with all rules and regulations of Emergency Services Academy Ltd. Applicant s Signature Date The collection of this personal information is necessary for operating and administering the services of the ESA Registry. All personal information will be protected under the provisions of the Alberta Freedom of Information and Protection of Privacy Act. Page A-5

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