University of Minnesota Emergency Medical Services



Department of Emergency Management · 2221 University Avenue SE · Suite 140 · Minneapolis, MN 55414

Telephone 612-626-1312 / Fax 612-625-6660 · umems@umn.edu ·

Application for UMEMS Education Courses

Please fill out this form electronically. If you are unable to do so, please type or print all information neatly.

General Information

|Last Name |First Name |M.I. |Today's Date |Cell Phone | |

|      |      |      |      |      | |

|Local Address |City |State |Zip Code |Phone Number |

|      |      |      |      |      |

|Permanent Address |City |State |Zip Code |Phone Address |

|      |      |      |      |      |

|Email Address |Driver License Number |State of Issue |

|      |      |      |

Additional Information

|Have you ever been convicted of a felony? |Y |N |

|Have you ever been convicted of DUI/DWI in any State or Province? |Y |N |

|Has your driver's license ever been revoked? |Y |N |

|Has your driver's license ever been suspended? |Y |N |

|Has your EMR/T certification ever been revoked or denied or is it pending such action? |Y |N |

|Have you ever been excluded from a federally funded healthcare program? |Y |N |

|If you answered Yes to any of the previous questions, please list explanation on a separate sheet of paper. |

Currently Held Certifications

|**Required prior to completion of class |Expiration Date |Certificate Number |

|EMR or EMT Certification |      |      |

|**AHA CPR BLS Healthcare Provider |      |N/A |

|or Red Cross BLS Healthcare Provider | | |

|Other |      |      |

Course Information

|Which Course Are You Applying For (select one): |EMT Only |EMT and AHA CPR |

|Course Dates: Tuesdays and Thursdays from 5:30pm until 10pm. June 12, 2018 until August 16, 2018. |

|*Note: Class will NOT be held the week of July 4. No class July 3 & July 5. |

| |

|Cost of EMT Course alone: $1,700.00 USD (includes books and clinical fees) |

|Cost of EMT and CPR course: $1,773.00 USD (includes books and clinical fees) |

| |

|CPR Course will be held on a separate date and time dependent on number of students needing the course. |

Please return this completed application with full payment to be considered for the course.

You may return this completed application by mail or in person during regular business hours to the Department of Emergency Management - UMEMS, Suite 140, 2221 University Avenue SE, Minneapolis, MN 55414. Please email umems@umn.edu if you have any questions. Space is filled on a first come, first served basis.

Thank you for your interest in the University of Minnesota Department of Emergency Management – UMEMS’ Emergency Medical Technician (EMT) Course.

Please read these instructions completely before proceeding.

Here you will find a two page contract that, along with this page, serves as an application for enrollment to our course. The tuition price does not cover the cost of parking. American Heart Association CPR for Healthcare Providers is a requirement for EMT classes. If you do not already have AHA CPR certification (or the equivalent American Red Cross Healthcare Provider CPR training) you may select to receive CPR certification for an additional fee. CPR certification must be completed prior to course enrollment and/or not expire within six months of course completion. Because we are not offering courses for credit through the University of Minnesota, the EMT class is not eligible for financial aid.

Academic Credit: This is a non-credit class.

Refund Policy: The following refund policy applies to all classes taught by University of Minnesota Emergency Medical Services.

Cancellation prior to first class: 100% refund

Withdrawal after completion of first class: no refund except by extenuating circumstances

All applicants must submit the entire tuition payment along with this application in the form of a check or money order payable to “The University of Minnesota.” A returned check fee of $30 will be assessed on all returned checks.

The undersigned applicant for enrollment to the University of Minnesota Department of Emergency Management – UMEMS’ EMT Course of instruction understands and agrees to all of the following terms and conditions without exception:

1. Course Size: Course size will be determined prior to the start of the class. If fewer than 10 completed applications and tuition payments are received by the close of business on or prior to the deadline date, the course will be cancelled and reimbursements will be distributed to all applicants. Students will be accepted on a first come, first served basis.

2. Application Deadline: Applications will be accepted until the course is full or until the application deadline date of Tuesday, May 29, 2018. Should the course be filled or cancelled, you will be notified.

3. Tuition and Fees/Penalties: Cost includes tuition and textbook materials.

Tuition for EMT: non-active/non-UMEMS members: $1,700.00

Tuition for AHA CPR Healthcare Provider: non-active/non-UMEMS members: $73.00 active UMEMS members: FREE

Active status is defined under the UMEMS Accountability policy. Free courses are only available to ACTIVE members.

If 10 or more applications are received prior to the deadline, the course will go ahead and the tuition will not be refundable in whole or in part. All funds are to be payable in U.S. dollars by check or money order payable to "The University of Minnesota" and must accompany the application. I agree to pay a $30 fee should my check be returned.

4. Medical: I understand that as part of the course of instruction, I will be placed in close contact with other students and actual patients. Such contact may result in my contact with diseases and human blood or body fluids, and/or items contaminated with blood or body fluids. By my signature on this application, I hereby release and agree to hold harmless the University of Minnesota, the Department of Emergency Management, the University of Minnesota Emergency Medical Service, the University of Minnesota Medical Center, the Minneapolis Fire Department, and their respective employees and agents from any and all damages that might result from such contact. I further understand, that while it is not a requirement for admission to or participation in this course, all students are urged to seek out and obtain vaccinations against Hepatitis B prior to attending the course. I agree to provide proof of current negative tuberculosis status and proof of current vaccination against Measles, Mumps and Rubella. Further, I understand that as part of the course I will be performing strenuous physical activity, including, but not limited to, lifting weights in excess of 100 (one hundred) pounds and that the course will also require the use of motor vehicles, medical equipment and power and hand tools. By my signature below, I hereby certify that I have consulted a physician and my physical condition will allow me to participate without risk to myself or others and I release and agree to hold harmless the University of Minnesota, the Department of Emergency Management, the University of Minnesota Emergency Medical Service, the University of Minnesota Medical Center, the Minneapolis Fire Department, and their respective employees and agents from any and all damages which might result from such activity or use.

5. Successful Completion: I understand that in order to successfully complete the course I must attend all class sessions.

In addition, to successfully complete the course I must pass both the overall course practical and written final examinations. Completion of this course will make me eligible to become certified or recertified as a Minnesota Certified Emergency Medical Technician.

6. I certify that I am at least 18 years of age or will be at the completion of the course, and I have thoroughly reviewed this document and agree to the terms and conditions of this contract without reservation or purpose of evasion.

7. I understand that I must provide information to and successfully pass a criminal background check prior to completing the course.

8. I am enclosing a copy of my current American Heart Association CPR for Healthcare Professionals card or American Red Cross BLS for Healthcare Professionals card (issued within the last year), which I understand is a requirement of this class, or I am enclosing an additional amount of $73.00 to cover the cost of this training.

Signature or Typed Name: Date:      

If the applicant is under eighteen (18) years of age, please have the parent or legal guardians of the applicant also sign below:

I, , am the mother/father or legal guardian of the person who signed above, and I give my unqualified permission and consent for them to participate in the University of Minnesota Emergency Medical Technician class. I am legally competent to sign this form and represent that the information contained herein is true and correct to the best of my knowledge.

Signature or Typed Name: Date:      

Please return this completed application with payment to the DEM.

You may return this completed application by mail or in person during regular business hours to the Department of Emergency Management -UMEMS, Suite 140, 2221 University Avenue SE, Minneapolis, MN 55414. Please email umems@umn.edu with any questions.

The University of Minnesota is committed to the policy that all persons shall have equal access to its programs, facilities, and employment without regard to race, color, creed, religion, national origin, sex, age, marital status, disability, public assistance status, veteran status, or sexual orientation.

In adhering to this policy, the University abides by the Minnesota Human Rights Act, Minnesota Statute Ch. 363; by the Federal Civil Rights Act, 42 U.S.C. 2000e; by the requirements of Title IX of the Education Amendments of 1972; by Sections 503 and 504 of the Rehabilitation Act of 1973; by the Americans with Disabilities Act of 1990; by Executive Order 11246, as amended; by 38 U.S.C. 2012, the Vietnam Era Veterans Readjustment Assistance Act of 1972, as amended; and by other applicable statutes and regulations relating to equality of opportunity.

Inquiries regarding compliance may be directed to the Director, Office of Equal Opportunity and Affirmative Action, University of Minnesota, 419 Morrill Hall, 100 Church Street S.E., Minneapolis, MN 55455, (612) 624-9547.

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