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 2^nd 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.
d) Asthma, emphysema, or other lung conditions.
e) Tuberculosis or exposure to tuberculosis.				o) Drug or narcotic habit such as marijuana, cocaine, heroin, LSD, or any derivatives.
f) High/low blood pressure, heart disease.
g) Stomach, liver (hepatitis), gallbladder disease.				p) Bleeding disorder. blood disease, sickle cell anemia.
h) Hernia (rupture)/Genito-Urinary/Rectal Disorder.				q) Tumour, abnormal growth, cyst, or cancer.
i) Kidney or bladder condition, stone or blood.				r) Skin disorder growths psoriasis.
j) Diabetes, sugar in the urine.				s) Gynaecological disease/abnormal menses.
k) Joint disease or injury, swollen or painful joints.				t) Hearing impairment.
l) Back pain, or spinal condition, use of back brace.
7. If you answered “YES” to any item in Question 6, please explain in detail (include dates of occurrence, treatment, and outcome):

MEDICAL HISTORY AND EXAMINATION FORM

II. Physical Examination Form

THIS PHYSICAL EXAMINATION FORM MUST BE COMPLETED IN ENGLISH BY A DESIGNATED AND QUALIFIED PHYSICIAN AFTER REVIEWING THE EXAMINEE’S MEDICAL HISTORY (PART I), CONDUCTING A PHYSICAL EXAMINATION, AND ASSESSING LABORATORY AND X-RAY RESULTS. THE EXAMINING PHYSICIAN MUST COMMENT ON ALL POSITIVE AND/OR SIGNIFICANT FINDINGS AND SIGN WHERE INDICATED.

PLEASE TYPE OR PRINT IN INK

1. APPLICANT NAME:
Last					First		Other
2. HEIGHT:			3. WEIGHT:		4. CORRECTED VISION: 20: 20:
5. BLOOD PRESSURE:		6. TEMPERATURE			7.. PULSE: Circle whether regular or irregular
8. URINALYASIS:
	Sugar			Albumin		Microscopic examination
9.ELECTROCARDIOGRAM REPORT (If indicated by history or physical examination):
10.CLINICAL EVALUATION: Abnormal findings must be fully explained in the space provided.) NORMAL ABNORMAL COMMENTS
a) Head, Nose, Mouth.
b) Ears, Hearing Acuity.
c) Eyes, Visual Acuity.
d) Lungs and Chest/Breast.
e) Heart, Rhythm and sounds.
f) Vascular System.
g) Abdomen, Hernia, etc.
h) Rectum/Prostate, Haemorrhoids, Fistula.
i) Urinary System.
j) Spine and Extremities.
k) Skin, Lymph Nodes, Scars.
l) Neurological System/Reflexes.
m) Emotional Stability.
11.THE PHYSICIAN MUST COMMENT ON ALL ITEMS MARKED “YES” IN THE MEDICAL HISTORY (PART I) AND COMMENT ON ANY CONDITION DISCOVERED DURING THE EXAMINATION. PHYSICIAN’S SUMMARY STATEMENT AND DIAGNOSIS: I have completed my physical examination to the best of my knowledge and have reviewed the applicant’s medical history, laboratory evaluations, and immunization record. It is my opinion that the applicant’s physical and emotional condition is satisfactory for a full course of study, research, and clinical performance and that there are no limitations on activity or special assistance expected for the duration of the period proposed. YES NO 12.
. SIGNATURE: DATE: