PARAMEDIC PROGRAM COURSE APPLICATION             

 

                              Name: __________________________________________ Date of Birth ____________

                                         First            Middle                        Last

 

Home Address: _______________________             City/Town: ________        State: __Zip+4______

 

Telephone (Home) ___________ Work ________ Pager __________Cell___________Nextel________

 

Social Security #: __________________Driver’s License # _______________ Exp. Date ______

Email address: _________________________

Level of Certification: ___________             Certification #: _________ Exp. Date: ________

CPR card expires ___/___

 

Number of years as EMT at any level: ________________

Has your certification ever been suspended/revoked or subject to discipline?  Yes__NO__
(If yes, attach explanation on separate paper)

 

Current or Primary EMS Employer/Service

Organization Name: ___________________________ Telephone: _____________

Address: ______________________________  City/Town: _______ State: ______

Position: ________________________Date Employed:__/__ Status (FT/PT/Vol)_____

Duties:   ______________________________________________________________

______________________________________________________________

               

Supervisor (print name) _____________________________

I hereby confirm that the above listed information is accurate and truthful.

Supervisor’s Signature: __________________________ Date: _________

 

Secondary EMS Employer/Service

Organization Name: ___________________________ Telephone: _____________

Address: ______________________________  City/Town: _______ State: ______

Position: ________________________Date Employed:__/__ Status (FT/PT/Vol)_____

Duties:   ______________________________________________________________

______________________________________________________________

               

Supervisor (print name) _____________________________

 

 

Attach copies of:
EMS certs     CPR    Drivers license   Birth Certificate   HS / College graduation   Immunizations
(revised 02/04)

 

Return completed application to:  JHPC Paramedic Program    200 Mill Hill Ave 2nd Floor    Bridgeport, CT 06610  Attention: Barry Barkinsky



               

JOINT HOSPITAL PLANNING COUNCIL

PARAMEDIC PROGRAM

EDUCATIONAL BACKGROUND

 

EDUCATION:

College: _____________________________________________________

Address: _____________________________________________________

Degree: ____________________________________  Date: ____________

If no degree, current credit standing: _____________  Major: ___________

High School Attended: __________________________________________

Diploma/GED: _________________________  Date: _________________

EMT initial class taken at: _______________________  month/year ___/____

Advanced certification level of _____________  taken at__________ month/year ___/__

 

Advanced certification level of _____________  taken at__________ month/year ___/__

 

Other non EMS certifications held: __________________________________________

 

Hobbies and interests: _____________________________________________________

 

MILITARY SERVICE:

Branch: ____________________________________________

Dates of Service:         From: ________________ to ______________

 

Duties: _________________________________________   Rank: _____________

 

Reserve Status: _____________________________________

 

Have you had any felony or criminal convictions other than traffic violations within the last three years?

YES                                                NO

If YES, attach a note of explanation in an envelope sealed and marked “CONFIDENTIAL”.

I attest that all information in this application is correct and truthful.

Applicant Signature: __________________________________________________

Date:   ________________________________

 

 

 

JOINT HOSPITAL PLANNING COUNCIL

PARAMEDIC PROGRAM

 

 

RELEASE OF INFORMATION

 

 

Authorization to release information to the Joint Hospital Planning Council Paramedic Program.

 

To:          _________________________________________

 

 

I, ______________________________________ authorize the release of information to

(Applicant)

the Joint Hospital Planning council Paramedic Program, any information necessary to evaluate my credentials or health relative to my application for EMT-Paramedic Training.  This release is valid for a period of one (1) year from this date.

 

 

Applicant Signature: ______________________________________

 

Date:      _____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

Notary Public: _______________________________

Commission expires: __________________________

Date:      _______________________

 

 

 

JOINT HOSPITAL PLANNING COUNCIL

PARAMEDIC PROGRAM

 

 

 

HEALTH INSURANCE WAIVER

 

I, __________________________________ understand that in the course of my

(Applicant)

paramedic training, I may have an increased risk of exposure to hazardous situations and/or infectious diseases.  I agree to maintain personal health insurance during my training and understand that the Joint Hospital Planning Council Paramedic Program will not provide such coverage.  Furthermore, the Joint Hospital Planning Council Paramedic Program will not provide Workman’s Compensation insurance to students for training related illness or injuries.

 

 

Applicant Signature: _______________________________________________

Date:      _______________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

Notary Public: ___________________________________________

Commission Expires: _____________________________________

Date:      ________________________________________

 

 

 

 

 

 

JOINT HOSPITAL PLANNING COUNCIL

PARAMEDIC PROGRAM

 

 

 

 

SUBSTANCE ABUSE FORM

 

 

 

 

To Whom It May Concern:

I, __________________________ certify that I am not actively addicted to alcohol or

(Applicant)

other drugs. I certify that I have no substance abuse or alcohol problems and that I do not use illegal drugs.

 

 

 

 

Applicant Signature: _______________________________

Date:      __________________________________

 

 

 

 

 

 

Notary Public: __________________________________________

Commission Expires: ____________________________________

Date:      _____________________________________________

 

 

 

 

 

 
 

 

JOINT HOSPITAL PLANNING COUNCIL

PARAMEDIC PROGRAM

 

 

 

HEPATITIS B FORM

 

 

I, _____________________________ have been advised by the Joint Hospital Planning

(Applicant)

Council Program that I should be vaccinated against Hepatitis B, and if I decline I understand that contracting the illness may have serious consequences.

 

 

 

 

 

Applicant Signature: ___________________________________

Date:      ____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

Notary Public: ____________________________________________

Commission Expires: ______________________________________

Date:      _____________________________

 

 

 

 

 

 

JOINT HOSPITAL PLANNING COUNCIL

PARAMEDIC PROGRAM

 

 

 

IMMUNIZATION RECORDS

 

The Joint Hospital Planning Council Paramedic Program, to be consistent with Public Act 89-90 effective July 1, 1989, will require anyone born after 12/31/56 provide proof of immunization for Measles, Rubella, Mumps, Polio, Tetanus/Diphtheria within five years and a Mantoux Skin test for tuberculosis within six months.  Each candidate must have copied documentation of the following:

 

1.                   Proof of age

2.                   Proof of vaccination via titer

3.                   Proof of disease by Physician’s Certificate

 

 

It is also strongly suggested that each student be immunized against Hepatitis B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JOINT HOSPITAL PLANNING COUNCIL

PARAMEDIC PROGRAM

REFERENCE SHEET

 

EMS Service Chief

Name: _______________________________________________________________

Address: ________________________________________________________________

City                                State                       Zip Code

Phone #: ______________________________________

 

Emergency Department

M.D., P.A., or R.N.  Name: ____________________________________________

Address: ____________________________________________________________

City                                State                       Zip Code

Phone #: _______________________________________________

 

Peer EMS Provider

Name:    _____________________________________________________________

Address: ___________________________________________________________

City                                State                       Zip Code

Phone #: _________________________________________

 

 

Peer EMS Provider

Name:    _____________________________________________________________

Address: ___________________________________________________________

City                                State                       Zip Code

Phone #: _______________________________________

 

Name two individuals who could be notified in case of an emergency

Name:   

     

Address:

     

 

     

Telephone number(s):

     

Relationship:

     

Name:   

     

Address:

     

 

     

Telephone number(s):

     

Relationship:

     

 

I certify that I have reviewed the foregoing information supplied by me, and that it is true and complete to the best of my knowledge. In the event of a serious illness or medical emergency during the grant activity, I authorize release of my medical records to the designated contractual agency. 

        I understand that if any of this information is found to be substantially inaccurate or incomplete, it may be grounds for withdrawal from the program.

 

 

SIGNATURE:

 

 

 

DATE:

 

     

 
 

 

 

 MEDICAL HISTORY AND EXAMINATION FORM

 

I. MEDICAL HISTORY

 

MEDICAL HISTORY MUST BE COMPLETED BY THE APPLICANT IN ENGLISH AND SIGNED BEFORE VISITING THE EXAMINING PHYSICIAN

PLEASE TYPE OR PRINT IN INK

Name:     

     

     

                   Last

First

Other

2. DATE OF BIRTH:        (Day/Month/Year)

3. SEX:     Male   Female

4. ADDRESS:             

 5.. Indicate “YES” or “NO”. “YES” answers MUST be explained In the space provided. (Additional space available on Page 2 of this form.)

 

YES

NO

EXPLANATION

a)       Have you ever had any significant or serious illness(es) or injuries? (State nature of problems/places/dates.)

     

b)       Have you ever had any operations or been advised by a physician to have an operation? (Details/dates.)

     

c)       Have you ever been a patient in a mental hospital or sanatorium or treated by a psychiatrist? (Give places/dates.)

     

d)       Do you currently take medication for treatment of a medical condition (list name) or do you require the use of a medical device?

     

 

. Do you now have or have you ever had any of the conditions listed below? (Check “YES” or “NO” for each Item.)

CHECK EACH ITEM

YES

NO

CHECK EACH ITEM

YES

NO

a)       Epilepsy, convulsions, fits.

m)      Tropical diseases (malaria, bilharzia, amoebiasis, leprosy, filariasis, yaws, etc.)

 

 

b)       Eye disease, vision defect in one or both eyes.

c)       Tooth or gum disease (periodontal disease).

n)       Depression, anxiety, attempted suicide or other psychological symptoms.