EMS Training Enrollment Application

Updated: 01 April 2014 EMS Training Enrollment Application Baraboo District Ambulance Service Training Center

List of Upcoming Classes Christopher Fiebig Training Center Coordinator Bryan Dekeyser Lead Instructor 120 5th Street Baraboo, WI 53913 Phone: 608.356.3455 E-mail: trainingcenter@barabooems.com Recurring Events Calendar EMT Summer Accelerated Initial Class: Starts first week of June Class: 10 weeks of instruction 2 days a week from 8:00 am to 4:00 pm Classroom Instruction reinforced with online content and clinical labs Class designed for those utilizing summer break from school but open to anyone. Very rapid paced class constructed to complete NREMT requirements by end of summer. EMT Fall Initial Class: Starts first week in September Class: 20 weeks of instruction 2 days a week from 6:00 pm to 10:00 pm Classroom Instruction reinforced with online content and clinical labs EMT Spring Initial Class: Starts second week in January Class: 20 weeks of instruction 2 days a week from 6:00 pm to 10:00 pm Classroom Instruction reinforced with online content and clinical labs AEMT Fall Initial Class: Starts first week in September Class: 20 weeks of instruction 2 days a week from 6:00 pm to 10:00 pm Classroom Instruction reinforced with online content and clinical labs AEMT Spring Initial Class: Starts second week in January Class: 20 weeks of instruction 2 days a week from 6:00 pm to 10:00 pm Classroom Instruction reinforced with online content and clinical labs American Heart Association Classes: AHA ACLS Renewal Class One renewal class each quarter: Please consult the Currently Scheduled Classes section or inquire by emailing: trainingcenter@bdems.com AHA PALS Renewal Class One renewal class each quarter: Please consult the Currently Scheduled Classes section or inquire by emailing: trainingcenter@bdems.com AHA CPR (BLS for Healthcare Providers) Every Last Thursday of each month 6:00 pm to 9:00 pm Note: All classes will be held at the Baraboo District Ambulance Training Center in RM 31 of the Baraboo Civic Center in Baraboo, Wisconsin if not listed otherwise.

Currently Scheduled Classes Initial Class Offerings: EMT Summer Accelerated Initial Class: June 12 th, 2014 Class: 11 weeks on Tuesdays & Thursdays 8:00 am to 4:00 pm Classroom Instruction reinforced with online content and clinical labs Open for enrollment now! EMT Fall Initial Class: September 9 th, 2014 Class: 21 weeks on Tuesdays & Thursdays 6:00 pm to 10:00 pm Classroom Instruction reinforced with online content and clinical labs Will be held in Baraboo EMT Fall Initial Class: September 9 th, 2014 Class: 21 weeks on Tuesdays & Thursdays 6:00 pm to 10:00 pm Classroom Instruction reinforced with online content and clinical labs Will be held at 1110 Leed Parkway, Plain, WI http://goo.gl/maps/anqyg Open for enrollment now! AEMT Fall Initial Class: September 8 th, 2014 Class: 21 weeks on Monday & Wednesday 6:00 pm to 10:00 pm Classroom Instruction reinforced with online content and clinical labs. Open for enrollment now! Refresher Courses: EMT & AEMT Transition Refresher Class for late licensure: August 25 th, 2014 Class: 1 week on Monday through Friday 8:00 am to 5:00 pm and Friday 8:00 am to 2:00 pm EMT s: 30 hours of instruction starting on Tuesday August 26 th, 2014 through Friday AEMT s: 42 hours of instruction starting on Monday August 25 th, 2014 through Friday 6 Hour Mini Refresher on Friday, June 20 th, 8:00 am Seating is limited, so please submit enrollment application and payment soon. Last refresher for the last biennium licensing period. Open for enrollment now!

American Heart Association Course Offerings: PALS Renewal Class June 23 rd, 2014 in Room 31 at the Baraboo Civic Center from 9:00 am to 3:00 pm Please inquire by emailing: trainingcenter@barabooems.com ACLS Renewal Class June 24 th in Room 31 at the Baraboo Civic Center from 9:00 am to 3:00 pm Please inquire by emailing: trainingcenter@barabooems.com CPR (BLS for Healthcare Providers) Every Last Thursday of each month 6:00 pm to 9:00 pm Please inquire by emailing: trainingcenter@barabooems.com Note: All classes will be held at the Baraboo District Ambulance Training Center in RM 31 of the Baraboo Civic Center in Baraboo,Wisconsin if not listed otherwise.

EMERGENCY MEDICAL RESPONDER Class Information Demographics Course Length : 12 Weeks Course Time: 80 hours Clinical Time: None Required by the State of Wisconsin, but will participate in one 8 hour ambulance service shift. Class Sessions: Twice weekly from 6:00pm to 10:00pm Start Date: TBD National Registry Test Date: TBD Pre-Requisites AHA Basic Life Support for Healthcare Providers current certification Instruction Materials Title Publisher Author Delivery Prehospital Emergency Care 10th Edition BDASTC Student Handbook Jones & Bartlett Pollak, MD FAAOS Printed book with online content to reinforce classroom instruction BDASTC BDASTC Staff Printed BDASTC Student Workbook Jones & Bartlett Various BDASTC Instructors Online from J&B Learning website BDASTC Clinical & Lab Workbook BDASTC BDASTC Staff Printed for 3-ring binder Costs Item EMR Class Textbook & Workbook Clinical Uniform Shirt Practical Exam Written Exam Cost $600.00 (due at start of class includes lab & clinical fees) Book rental included T-shirt provided $100.00 (paid just prior to exam) $60.00 (approximately)

EMT Accelerated Summer Class Information Demographics Course Length : 11 Weeks Course Time: 160 hours Clinical Time: Minimum 16 hours Class Sessions: TBD o Morning Sessions: 8:00 am to 12:00 pm o Afternoon Sessions: 1:00 pm to 4:00 pm Start Date: TBD National Registry Test Date: TBD at course completion Pre-Requisites AHA Basic Life Support for Healthcare Providers current certification Immunizations current prior to starting clinicals as per Section 8 Immunization Form Instruction Materials Title Publisher Author Delivery Prehospital Emergency Care 10th Edition BDASTC Student Handbook BDASTC Student Workbook BDASTC Clinical & Lab Workbook Costs Item EMT Class Textbook & Workbook Clinical Uniform Shirt NREMT Practical Exam NREMT Written Exam Jones & Bartlett Pollak, MD FAAOS Printed book with online content to reinforce classroom instruction BDASTC BDASTC Staff Printed Jones & Bartlett Various BDASTC Instructors Online from J&B Learning website BDASTC BDASTC Staff Printed for 3-ring binder Cost $1,200.00 (due at start of class includes lab & clinical fees) Book rental included Included $150.00 (paid just prior to exam) $100.00 (approximately)

EMT Spring & Fall Initial Class Information Demographics Course Length : 21 Weeks Course Time: 160 hours Clinical Time: Minimum 16 hours Class Sessions: Tuesdays & Thursdays from 6:00pm to 10:00pm Start Date: TBD National Registry Test Date: TBD at course completion Pre-Requisites AHA Basic Life Support for Healthcare Providers current certification Immunizations current prior to starting clinicals as per Section 8 Immunization Form Instruction Materials Title Publisher Author Delivery Prehospital Emergency Care 10th Edition BDASTC Student Handbook Jones & Bartlett Pollak, MD FAAOS Printed book with online content to reinforce classroom instruction BDASTC BDASTC Staff Printed BDASTC Student Workbook Jones & Bartlett Various BDASTC Instructors Online from J&B Learning website BDASTC Clinical & Lab Workbook BDASTC BDASTC Staff Printed for 3-ring binder Costs Item EMT Class Textbook & Workbook Clinical Uniform Shirt NREMT Practical Exam NREMT Written Exam Cost $1200.00 (due at start of class includes lab & clinical fees) Book rental included. Included $150.00 (paid just prior to exam) $100.00 (approximately)

AEMT Spring & Fall Initial Class Information Demographics Course Length : 21 Weeks Course Time: 160 hours classroom & Lab Clinical Time: Minimum 50 hours Class Sessions: Monday & Wednesday from 6:00pm to 10:00pm Start Date: TBD National Registry Test Date: TBD at course completion Pre-Requisites AHA Basic Life Support for Healthcare Providers current certification State of Wisconsin EMT-Basic license Immunizations current prior to starting clinicals as per Section 8 Immunization Form Instruction Materials Title Publisher Author Delivery Advanced EMT 2 nd Ed. Jones & Bartlett Pollak, MD FAAOS Printed book with online content to reinforce BDASTC Student Handbook BDASTC BDASTC Staff classroom Printed instruction BDASTC Student Workbook BDASTC Various BDASTC Instructors Online from J&B Learning website BDASTC Clinical & Lab Workbook BDASTC BDASTC Staff Printed for 3-ring binder Costs Item AEMT Class Textbook & Workbook Clinical Uniform Shirt NREMT Practical Exam NREMT Written Exam Cost $1300.00 (due at start of class includes lab & clinical fees) Book rental included Included $200.00 (paid just prior to exam) $100.00 (approximately)

Course Fees Baraboo District Ambulance Training Center Jan 1, 2014 Initial Instruction Courses Course Duration Enrollment Cost Extra Expenses Estimate Notes: Emergency Medical Responder (EMR) 14 weeks $700.00 $0.00 course material provided Emergency Medical Technician (EMT) 21 weeks $1200.00 $0.00 course material provided Advanced Emergency Medical Technician (AEMT) AHA Basic Life Support for Healthcare Providers 21 weeks $1300.00 $0.00 course material provided 4 hours $75.00 $0.00 extra for book AHA Heartsaver CPR with AED 2 hours $50.00 $12.00 extra for book AHA Heartsaver CPR w AED & First Aid 6 hours $75.00 $12.00 extra for book AHA Blood Borne Pathogens 3 hours $50.00 $12.00 extra for book Refresher Courses Course Duration Enrollment Cost Extra Expenses Estimate Notes: Emergency Medical Responder (EMR) 3 days (18 hrs) $125.00 $0.00 Fees required EMT Full Refresher 1 wk (32 hrs) $300.00 $0.00 Remit fee with application AEMT Transition Refresher 1 wk (48 hrs) $400.00 $0.00 Remit fee with application Mini Refresher Only 1 day (6 hrs) $100.00 $0.00 Remit fee with application Paramedic Transition Refresher 2 wks ( 72 hrs) $600.00 $0.00 course material provided AHA Basic Life Support for Healthcare Providers 4 hours $75.00 $12.00 extra for book AHA Heartsaver CPR with AED 2 hours $50.00 $12.00 extra for book AHA Heartsaver CPR w AED & First Aid 6 hours $75.00 $12.00 extra for book AHA Blood Borne Pathogens 3 hours $50.00 $12.00 extra for book

Refresher Course Applicants: Complete Sections 1 and 2 and mail, fax or email the form to: EMR, EMT and AEMT Initial Course Applicants: Complete Sections 1 through 7 and mail, fax or email the form to: Baraboo District Ambulance Service Training Center 120 5 th St. Baraboo, WI 53913 Attn: Christopher Fiebig Fax: 608-356-3446 Email: trainingcenter@barabooems.com EMT and AEMT Students: Schedule an appointment with your Primary Care Physician and have your doctor complete Section 8 by the first week of class.

SECTION 1: PERSONAL INFORMATION NAME: HOME ADDRESS: Baraboo District Ambulance Service Training Center (First) (MI) (Last) CITY/STATE/ZIP: E-MAIL/INTERNET CONTACT: MOBILE PHONE: HOME PHONE: WORK PHONE: SOCIAL SECURITY NUMBER: DATE OF BIRTH: GENDER: OPTIONAL ALL INFORMATION GIVEN BELOW IS CONFIDENTIAL and is used for our enrollment reporting only. Educational History: Less Than a High School Diploma High School Graduate/GED Name of High School Attended: Graduation Date (Optional) Technical School Diploma Some College, No Degree College Graduate Post-Secondary School/College/University Attended RACE:

This page intentionally left blank.

SECTION 2: PROGRAM OF STUDY Indicate Class Interest: Emergency Medical Technician Baraboo District Ambulance Service Training Center Fall Class Spring Class Summer Accelerated Class evening class below Advanced Emergency Medical Technician Fall Class Spring Class Refresher Classes EMT: 1 week class only (32 hours of instruction for State of Wisconsin EMS Re-licensure) EMT: Mini refresher class only (6 hours of instruction for State of Wisconsin EMS Re-licensure) AEMT: 1 week class only (48 hours of instruction for State of Wisconsin EMS Re-licensure) AEMT: Mini refresher class only (6 hours of instruction for State of Wisconsin EMS Re-licensure) Paramedic : 2 week class (totals 72 hours of instruction for NREMT requirements) American Heart Association Classes ACLS Initial Class PALS Initial Class ACLS Recertification PALS Recertification Other Classes:. Indicate Time Preference: (only necessary if morning & evening classes offered on the same day) Morning (8:00 12:00 AM) Evening (6:00 10:00 PM) All Day (8:00am 4:00 PM) Indicate Location Preference: Baraboo Other: Please list any modifications/accommodations needed in order to be successful in the assessment process or the program of study:

This page intentionally left blank.

Please Note: Those individuals with services providing payment for class and materials will still be billed individually and required to arrange payment from their respective services. Baraboo District Ambulance Service Training Center holds the student responsible for payment but will be happy to Co-invoice the sponsoring service as well as the student. The responsibility to clear any payment or sponsoring agreement is completely between the student and the sponsoring service. In any event of default of payment, Baraboo District Ambulance Service Training Center will pursue legal matters with the student only. It is incumbent upon the student to secure agreement paperwork from the sponsoring service prior to making arrangements for starting class or risk being held liable for payment. If you have any questions regarding this policy please feel free to contact us at your earliest convenience. Thank You. Note: If student is being sponsored by a service, an authorizing agent must be listed below with full contact information and signature. Method of Payment Check Credit Card Other: Explain : Payment due in full prior to start of class. Authorizing Agent s Contact Information Sponsoring service: Authorizing Agent: Agent s signature: Date: Address: City, State, Zip: Phone number:

This page intentionally left blank.

SECTION 3: STUDENT RELEASES Student Information/Confidential Records Students must grant permission for Baraboo District Ambulance Service Training Center to obtain and/or transfer student information, including confidential records from/to educational institutions or training location, present and prospective employers, social service agencies, mental health professionals, or sponsoring agencies as deemed appropriate. Student Signature: Date: Photo/Video Images Student signature acknowledges permission for the use of said student s photographic likeness and related statements in preparation and distribution of advertising, promotional material, instructional media, etc. including but not limited to: videos, multimedia presentations, web-based and print curriculum, brochures, and other functions attesting to the positive promotion of Baraboo District Ambulance Service Training Center. Conditions of this release state that approved photographic likeness will not be utilized for any other purposes such as profit or economic gain, and all photographs/images remain the property of Baraboo District Ambulance Service Training Center. Student Signature: Date: SECTION 4: TECHNOLOGY USE AGREEMENT Use of Computing Resources and Internet Use All Baraboo District Ambulance Service Training Center Students must agree to participate in the use of computing resources and use of the Internet for course content distribution. An in-depth guideline is available within the BDASTC Student Handbook that lists the terms and conditions of appropriate and required use of technology and lists the penalties for inappropriate use. Students will be given copies of the Student Handbook after successful registration along with an expectation that guidelines will be followed. Students who do not agree to the terms and conditions of the Policy will be denied enrollment; students who sign the agreement and then violate policies will subject to disciplinary action including possible suspension or expulsion from school. The students will all be expected to be proficient enough using personal computers for internet access. Students will be required to check periodically for course information and administrative announcements. By signing this agreement the student acknowledges understanding of the technology requirements by BDASTC and the ability to comply. The student must have adequate access to the internet or the ability to study in a public location with internet access. The student must have the ability to utilize the following programs for content review: Microsoft Office Products, Adobe Acrobat Reader and Flash Player and VLC Video player. Resolving technical difficulties will be the sole responsibility of the student. There are no exceptions to the electronic use requirement as it is a vital component of the learning environment. Student Signature: Date:

This page intentionally left blank.

SECTION 5: SAFETY, MEDICAL, AND EMERGENCY INFORMATION Health and Safety It is understood that students will be instructed in the correct safety procedures and proper use of equipment before being allowed to operate the equipment. Each student must assume personal responsibility for following safe practices and agree to the following general safety code: 1. Follow all safety rules. 2. Do not use equipment without first having permission from the instructor. 3. Do not use a particular piece of equipment unless you have been instructed on its use. 4. Report any accident or injury to the instructor immediately. 5. Understand that a violation of safety procedures may be reason for discipline including possible termination from the program. Medical and Special Needs Information (please write NONE if the item does not apply) Allergies: Specific medical problems: Physical disabilities or limitations: Other medical conditions: Prescriptions/medications currently being taken: Barriers to Learning or Educational Limitations: Section 8: Immunization Information must be removed and taken to your primary care physician for review and completion. Failure to have this completed by the first week of class will result in disenrollment from class as it will negatively affect your ability to participate in clinical activities. Emergency Information: It is understood that consent is given in advance of emergency treatment required while student is attending school or participating in school-related activities and that school personnel will exercise their best judgment should action be warranted to ensure student s safety, life, and health. In case of an emergency situation, attempts will be made to contact a designated emergency contact. Emergency Contact: Person: Relationship: Address: Phone Numbers:

This page intentionally left blank.

SECTION 6: STUDENT INFORMATION Student Handbook Students will be given a copy of the Baraboo District Ambulance Service Training Center Students (BDASTC) Student Handbook at the beginning of the school year. It is each student s responsibility to review the information contained in the handbook and abide by the rules and regulations. Several important aspects of information in the Student Handbook are summarized below. Please review each. Code of Conduct: Students are expected to conduct themselves in an appropriate manner at all times. If misconduct occurs at BDASTC, on school property, or on school sponsored activities, disciplinary actions will be taken by BDASTC. Misconduct at BDASTC can lead to suspension or termination from the program of study. Attendance Policy: It is the policy of BDASTC that students must attend a minimum of 90% for successful completion of the Career Tech program of study. Students who do not maintain this minimum requirement may be dismissed from BDASTC and denied a passing grade. Extended illness confirmed by a doctor s statement, or absences deemed unavoidable by the school administrator will not be charged against the minimum attendance requirement. Drug-Free School and Campuses Program: BDASTC commits to a continuing good faith effort to maintain a drug-free environment. The Code of Conduct for students explicitly prohibits the unlawful possession, use, being under the influence, or distribution of drugs or alcohol on school property or as any part of a school activity. Each student is hereby notified that as a condition of enrollment, the student must agree, in writing, to abide by the terms of this policy. Background Investigation: Students will be providing to the State of Wisconsin the information necessary and the permission necessary to perform a background investigation prior to the granting of a training permit. This permit is necessary for clinical participation and therefore is necessary for the continuation of class. Failure to complete clinicals will be failure to complete the course of instruction and will result in the inability to take the NREMT practical and written exam necessary for licensure as an EMT in the State of Wisconsin. It is incumbent on the student that he or she ensure that there are no outstanding issues relating to indictments or convictions greater than parking tickets or other minor offenses prior to the start of class. If the student has concerns regarding any possible barrier to the granting of a training permit due to past legal actions, the student has to inform the Course Instructor immediately upon start of class to ensure a timely processing of issues by the state EMS office. Student Agreement: Signature indicates that the student has read and understands the above information on Student Handbook, Code of Conduct, and Attendance Policy, as well as the Internet Agreement in Section 4 and the Safety Information in Section 5, and agrees to abide by the guidelines therein. Student Signature: Date:

This page intentionally left blank.

SECTION 7: GENERAL EDUCATION SKILLS REQUIREMENT GED Level Education Baraboo District Ambulance Service Training Center (BDASTC) Students will need to have reading, writing, mathematical and science skills equivalent with a standard high school education. Adult education students that have been out of the high school or college environment for an extended period of time should refresh their knowledge base and skills toward mathematics and comprehension. Students will be required to calculate mathematics, use fractions and write reports with standard English. If the student feels weak in any of the areas outlined, then it is incumbent on the student to achieve proficiency in these areas prior to class or request assistance immediately upon class start. Subject Matters: Specific areas of study are of particular importance to the EMT or AEMT student to include: Anatomy and Physiology The first learning unit of BDASTC EMT or AEMT course will include a rudimentary instruction on physics, chemistry and biology as it relates to human physiology. This instruction will form the base of knowledge the rest of the course will build upon. It is incumbent on the student to be prepared for an intense instruction on human Anatomy and Physiology and would greatly benefit with preparatory study prior to class on the major body systems and their function. If you have not previously participated in any health related courses or physiology courses in high school then you should start reviewing A&P content immediately upon acceptance into the EMT or AEMT program. Mathematics The BDASTC EMT or AEMT student will need to be proficient in addition, multiplication, subtraction and division of whole numbers and fractions. In addition to these basic skills student will be instructed on the dimensional analysis method of conversion. If the student is not proficient in basic math skills it is incumbent on the student to become proficient prior to class starting or inform the instructor prior to class start for assistance. There will be math and comprehension type problems on section tests and no special considerations will be made due to inability to calculate math problems. Once finished with class and during clinical rotations, the student will be expected to perform mathematical calculations in relation to pharmacological administration and a basic proficiency in math is necessary for proper performance as an EMT or AEMT. Critical Thinking Skills The BASTC EMT or AEMT student will be presented with complex multivariable situations in which a strong ability of problem solving and competent scene management is required. The student will need to be able to sort through information from various sources including simulated patients. The student will then have to determine the relevance of that information and make patient care decisions based on good analysis. If the student has a difficult time processing information from multiple sources and applying prioritization techniques then he or she should research developing critical thinking skills and practice exercises toward building skills in problem solving and observation techniques. Student Agreement: Signature indicates that the student has read and understands the above information on Educational Skills Requirement and agrees to ensure preparedness as outlined by the guidelines therein. Student Signature: Date:

This page intentionally left blank.

SECTION 8: IMMUNIZATION INFORMATION Baraboo District Ambulance Service Training Center Name Birth Date PROOF OF THE FOLLOWING IMMUNIZATIONS IS REQUIRED PRIOR TO CLINICALS MMR (Measles, Mumps, Rubella) TWO injections since age one. HEALTH HISTORY FORM STUDENTS: DO NOT WRITE ON THIS SIDE KEEP A COPY FOR YOUR RECORDS ALL STUDENTS BORN ON OR AFTER JANUARY 1, 1957 MUST PROVIDE PROOF OF IMMUITY TO MEASLES AND MUMPS. ALL STUDENTS MUST PROVIDE PROOF OF RUBELLA ACCEPTABLE PROOF IS CONSIDERED TO BE: Dose: 1 Date 1. RECORD OF IM M UNIZATION SIGNED BY A M EDICAL PROVIDER Dose: 2 Date 2. DOCUM ENTATION OF M EASLES, M UM PS AND/OR RUBELLA BY PHYSICIAN OR HEALTHCARE PROVIDER M EASLES, M UM PS AND RUBELLA CAN ALSO BE PROV EN BY PROTECTIV E TITER LAB REPORT M UST BE ATTACHED FOR COM PLIANCE Tetanus/Diphtheria/ Pertusis Booster within 10 years Date Hepatitis B Vaccine (series of 3) Varicella Vaccine (series of 2) Date Date Date Date Date AND OR Date of Titer POS / NEG Date of Titer: POS / NEG Lab report must be included for compliance Influenza (required to be within last 12 months) TB Skin Test (required annually) Lab report must be included for compliance Date Two-step TB skin test is not required for those who have documented evidence of current annual screenings. Documented evidence must include current year's screening and the past year's documentation. First Year Past Year OR Step 1 TB Test Date Date Read Results mm Step 2 TB Test Date Date Read Results mm If positive, date of last chest x-ray report must be provided. If the chest x-ray is positive, proof of treatment is required. HEALTHCARE PROVIDER INFORMATION Signature of person performing the examination Date Print name and Title ( ) 7/10/14 Clinic or Office BDASTC Phone Form Version 19.8.0 Address City/State Zip

This page intentionally left blank.