UACTI EMT Program Application Information:

UACTI EMT Program Application Information: Tuition for the EMT program is $925 plus a $25.00 nonrefundable application fee. Tuition includes a uniform shirt and textbook. Tuition also includes the student liability coverage premium that is required for all students to participate in the clinical portion of the program. It is the responsibility of the EMT student to obtain the required materials for the EMT Program. The required materials include: Penlight Stethoscope Blood Pressure Cuff Trauma Shears Navy Blue EMS pants Black Boots Black Belt Required materials may be purchased from: The Fire Store 104 Independence Way Coatesville, PA 19320 (see enclosed brochure) Or any other retailer. Students MUST have the required materials by the first class session. The $25 nonrefundable application fee payable to Uwchlan Ambulance Corps, completed application and all prerequisites must be returned to: Uwchlan Ambulance Corps 70 West Welsh Pool Road Exton, PA 19341 All prerequisites must be completed and submitted, along with the EMT Program application, no later than Tuesday June 30, 2015, 1500 hours. Students will be contacted for interviews upon receipt and verification of application. Notice of acceptance into the program will be given via email by July 31, 2015, 1500 hours. Application does not imply or guarantee enrollment. Any questions regarding the application process can be answered by contacting the UAC Training Coordinator at training@station87.com or by calling 610-363-1067 x 41. Page 1 of 11

Prerequisites for consideration into the EMT Program are: 1. Submission of current copy (dated within one year of application) of the following background checks in accordance with Act 34 and Act 151 as amended: a. Pennsylvania State Criminal History Record: https://epatch.state.pa.us/home.jsp b. Childline Child Abuse Clearance https://www.compass.state.pa.us/cwis/public/home c. Federal (FBI) Criminal History Report i. This fingerprint-based background check is a multiple-step process. Information and instructions can be found at www.pa.cogentid.com. 2. Submission of certificates of completion for the following online courses: a. ICS 100 i. http://training.fema.gov/is/courseoverview.aspx?code=is-100.b b. ICS 700 i. http://training.fema.gov/is/courseoverview.aspx?code=is-700.a 3. Completion and submission of the UACTI Health examination form. 4. Signed statement of Understanding from the Student Handbook. (Students under the age of 18 must have a parent or legal Guardian signature on this form. 5. Signed Uwchlan Ambulance Corps Release of Liability Form (students under the age of 18 must have a parent or legal Guardian signature on this form) 6. $25 non-refundable application fee check or money order payable to Uwchlan Ambulance Corps. No student will be admitted in the program with a disqualifying criminal history or child abuse clearance. Any student under the age of 18 at the start of class must have a parent or guardian attend the Pre-Class Administrative Session to complete any outstanding Pennsylvania Department of Health Forms. Page 2 of 11

Uwchlan Ambulance Corps EMT Program Application: Date: Last Name: First Name: MI: Home Address: City / State: Zip: Phone Number: Email: DOB: Shirt Size: Sponsoring Organization: Page 3 of 11

Release of Liability In consideration of being allowed to participate in any training, event or activity associated with the Uwchlan Ambulance Corps EMT Program ( Program ), I,, the undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the training, events and activities involved in this Program is significant, including the potential for permanent paralysis and death, while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist. 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN ARISING FROM NEGLIGENCE OF THE RELEASEES (as defined below) or others, and assume full responsibility for my participation in the Program. 3. Despite such risks, I willingly agree to participate in the Program and comply with the terms and conditions for participation in the Program, which I acknowledge receiving from UACTI and understand completely. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and will notify UACTI of such hazard immediately. 4. I certify that I am physically and mentally fit to participate in this Program and have not been advised by a qualified medical professional not to participate in this Program. I certify that there are no health-related reasons or problems which preclude my participation in this activity or event and have disclosed to UACTI any underlying medical conditions. 5. I certify that I currently have medical / health insurance to cover any injuries that I may sustain during my participation in this Program and agree that I will immediately notify UAC in the event I no longer have medical / health insurance. 6. I hereby indemnify, hold harmless, release and discharge Uwchlan Ambulance Corps, its affiliates, and their respective trustees, directors, officers, contractors, agents, and employees ( Releasees ) from any and all liabilities, suits, actions, claims, demands, damages, losses, expenses and costs of every kind and charater, including defense cost and legal fees ( Claims ), suffered or incurred to me, my employer, my assigns, my heirs, my executors, and personal representatives now and forever, for any and all Claims including but not limited Page 4 of 11

to: by reason or on account of injury to myself, or my property, whether by reason of accident, intent, or neglect during such time I am participating in the Program. In addition, I agree to indemnify and hold harmless the Releasees against all Claims suffered or incurred as a result of my conduct, whether it be negligent, accidental, or intentional, while I am a participating the Program. 7. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY, DEFEND AND HOLD HARMLESS the Releasees, WITH RESPECT TO ANY AND ALL LIABILITY, INJURY DISABILITY, DEATH or loss or damage to person or property, or expenses or fees (including reasonable attorney s fees) associated with my presence or participation in the Program, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 8. If any provision of this Release of Liability, or the application of such provision, shall be rendered or declared invalid by a court of competent jurisdiction, or by reason of its requiring any steps, actions or results, the remaining parts or portions of this Release shall remain in full force and effect. I HAVE READ THIS RELEASE OF LIABILITY, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Participant s Signature Age Date Signed Page 5 of 11

FOR PARENTS/ GUARDIANS OF PARTICIPANT OF MINORITY AGE (Under Age 18 at time of registration) This is to certify that I am the parent or guardian of the minor Participant named below, having legal responsibility for this minor, and I do hereby consent (with the approval of my spouse, if applicable) to the minor s participation in the Program and agree to the Release of Liability as provided above and hereby make and enter into each and every representation, certification, waiver, release, assumption and indemnity described above in the Release of Liability on behalf of myself, the minor, any other parent or guardian of the minor, and our heirs, assigns, personal representatives, and next of kin. I agree to give up my rights, the minor s rights, and the rights of any other parent or guardian to maintain any claim or suit against Releasees arising out of the minor s presence or participation in the Program. I believe and represent that I HAVE LEGAL AUTHORITY TO MAKE THESE WAIVERS AND RELEASES, and I agree to indemnity and defend the Releasees for all liability arising out of any lack of authority on my part to make such waivers and releases. Parent / Guardian Signature (print name) Date Applicant Name Page 6 of 11

INCOMING EMS CERTIFICATION STUDENT HEALTH EXAMINATION (PLEASE PRINT ALL INFORMATION) Name: Phone #: Date: DOB: Student Infectious Disease Summary In order to participate in any clinical experience / observation where there is potential for direct patient contact (hands-on-care to observing within a radius of 4 feet) it is necessary that the following information be provided and verified by your physician / nurse practitioner / physician s assistant. To meet the requirements of our affiliating clinical agencies, the following diseases, immunizations or titers MUST be documented. Pages 7-11 must be completed and signed by a certified healthcare professional. TUBERCULOSIS STATUS BLOOD TEST TB INTERFERON ASSAY (must be valid for the program year) Date: Results: Positive OR 2 Step Mantoux Skin Test (PPD) (must be valid for the program year) The two tests must be a minimum of 10 days and a maximum of 21 days apart. Date #1: Results: Positive Date #2: Results: Positive Those students with proof of previously documented 2-step and continuous yearly testing: Annual PPD Date: OR Results: Positive Page 7 of 11 If positive: Date of 2 View Chest X-Ray (completed within 1 year of date of admission):

MEASLES STATUS Rubeola IgG Antibody titer Date: Result: Positive OR Vaccination (given with MMR) 2 injections live virus vaccine on or after first birthday Date(s) / Type (2 injections): 1. 2. MUMPS STATUS Mumps IgG Antibody titer Date: Result: Positive OR Vaccination (given with MMR) on or after first birthday 2 injections live virus vaccine on or after first birthday Dates / Type (2 injections): 1. 2. VARICELLA (CHICKEN POX) STATUS Varicella IgG Antibody titer Date: Result: Positive OR 2 Doses Varicella Vaccine given 1 month apart: Dates: 1. 2. RUBELLA (GERMAN MEASLES) STATUS Rubella IgG Antibody titer Date: Result: Positive If negative or equivocal to the above, an MMR with follow up testing is required. MMR Administered: Yes No Date: Rubella IgG Antibody titer Date: Result: Positive (Follow-up test 4 to 8 weeks post vaccine) Page 8 of 11

TETANUS / DIPTHERIA / PERTUSSIS STATUS All students must show proof of 1 dose of Tdap administered after the age of 18. Date: If Tdap date is > 8 years old, student must have Tdap booster. Date: HEPATITIS B STATUS All students must be vaccinated against Hepatitis B prior to beginning clinical, or a Declination Form (see attached) must be completed. Hepatitis B is a series of 3 injections: Date 1: Date 2: Date 3: INFLUENZA STATUS All students are required to have the annual influenza vaccine if attending clinical between October and March. Date Administered: Vision Exam (Snellen Eye Chart or similar exam) Normal Referred for Correction Page 9 of 11

Review of Essential Qualifications I have obtained a health history, performed a physical examination, and reviewed the immunization status and required laboratory tests. In my estimation, the student is able to participate fully in the student EMT Program clinical experience in various health care agencies. In my opinion, the student is able to perform all of the following tasks without limitation, unless listed below: Verbally communicate in person and via telephone and telecommunications using the English language. Hear spoken information from co-workers, patients, physicians, and dispatchers and sounds common to the emergency scene. Lift, carry and balance a minimum of 125 lbs equally distributed (250 pounds with assistance), a height of 33 inches, a distance of 10 feet. Read and comprehend written materials under stressful conditions. Verbally interview patient, family members, and bystanders and hear their responses. Document physically in writing all relevant information in prescribed format. Demonstrate manual dexterity and fine motor skills, with ability to perform all tasks related to quality patient care. Bend, stoop, crawl and walk on uneven surfaces. Meet minimum vision requirements to operate a motor vehicle within the state. Function in varied environmental conditions such as lighted or darkened work areas, extreme heat, cold, and moisture. yes no COMMENTS: Page 10 of 11

1. Does the student have any activity limitations? yes no COMMENTS: 2. Does the student have any medical problems with which the school should be concerned? yes no If yes, please explain: 3. Does the student possess sufficient emotional stability to accurately perceive situations and make unimpaired observations and judgments regarding patient care in the clinical experiences of the health care program? yes no If no, please explain: 4. Based on your examination, is there a need for any follow-up treatment? yes no If yes, please explain: Does the student require a device or substance (including medications) to enable him/her to carry out the tasks required by the program? yes no If yes, please explain: Signature of healthcare provider Date Page 11 of 11