Hshshshshsh
Semester: _____________ Squad #: _______
Name: _______________________ ________________________
LAST FIRST
Email: ____________________________ Home Phone: ____________________
Cell Phone: ________________________ Pager: __________________________
Total number of units enrolled this semester: ___________
Occupation: ______________________________ Part-time Full-time
Reason for seeking EMT certification: ____________________________________________________________________________________________________________________________________________________________________________________
Documentation (Check off when placed in binder)
Proof of First Responder Training (copies attached)
Current AHA HCP CPR Certification (exp date: _________) (copies attached)
Signed Statement of Commitment (copies attached)
Proof of Immunizations (MMR) (copies attached)
Tuberculosis Clearance (copies attached)
Photo ID Tag Issued
Training/Mentoring/Testing Dates
Check when Completed
MCI/HAZ MAT training completed (Date: ________________)
Patient Packaging Training Complete (Date: _____________)
Mentoring Date: ____________ Hours completed: _________
Mentoring Date: ____________ Hours completed: _________
Mentoring Date: ____________ Hours completed: _________
Final Skills Test Date: ____________ Time: _______________
Clinical/Field Experience
Check when Completed
Hospital Location: ____________ Date: _____________ Times: __________
Hospital Location: ____________ Date: _____________ Times: __________
Field Location: _______________ Date: _____________ Times: __________
Field Location: _______________ Date: _____________ Times: __________
Verification Forms Complete (copies attached)
Clinical Essay Completed (copies attached)
Field Essay Completed (copies attached)
CVEMSA Application Completed (copies attached)
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.