PMTPrgrmBooklet - Amarillo College



Your Career In

Emergency Medical

Services Professions

Emergency Medical Technician-Basic

Emergency Medical Technician-Intermediate

Emergency Medical Technician-Paramedic

Associate in Applied Science Degree

and

Certificate Program

( 2008

Amarillo College

Division of Allied Health

Emergency Medical Services Professions

Thank you for your interest in the Emergency Medical Services Professions Program at Amarillo College. The department offers academic and continuing education curricula designed for people who desire to work in the field of emergency medicine. Our students range from initial certification students seeking to prepare themselves for that first ambulance ride to seasoned veterans of ground and flight services, hospital emergency departments and critical care units, and physicians’ offices and clinics seeking continuing education.

Our initial certification courses prepare students for certification and registry as Emergency Medical Technicians (EMTs). Initial students may successfully exit the program at any one of four levels of certification: EMT-Basic (EMT-B), EMT Intermediate (EMT-I), EMT-Paramedic (EMT-P/NREMT-P), or Licensed Paramedic (L.P.)

Amarillo College has been involved in Emergency Medical Services (EMS) Education since the inception of the industry. The Department of Paramedicine Technology was created in January of 1984. The program has evolved over the years to what it is today; The Department of Emergency Medical Services Professions. The advanced components of the curriculum were dramatically revised and the revisions were implemented in January of 1993. The latest curriculum revision was developed in 1998-1999 and will be implemented in June 2000. The advanced program is 1952 contact hours long, making it one of the most extensive EMS education programs. The program currently graduates 20-30 Paramedics annually from our on-campus program. Off-campus offerings are delivered as requested by communities and EMS Services in the Amarillo College service area. Basic classes are open admission; advanced courses are closed to accepted applicants, filled on a competitive admission process.

The EMSP program conducts classes both on, and off the Amarillo College West Campus and our students perform clinical rotations and field internships at various Amarillo area hospitals and Advanced Life Support/Mobil Intensive Care Unit Ambulance Services. These facilities expose our students to the latest, cutting edge pre-hospital and in-hospital medical experience and allow the students to work under the direct supervision of some of the finest medical and allied health professionals in the country.

Upon graduation, our students hold the following minimum credentials:

Texas Department of State Health Services-

Licensed Paramedic

EMT-Paramedic

EMS-Instructor at the basic and advanced levels (optional)

National Association of Emergency Medical Technician-

Pre-Hospital Trauma Life Support (PHTLS) Provider

National Registry of Emergency Medical Technicians-

Registered Emergency Medical Technician-Paramedic (NREMT-P)

American Heart Association-

Basic Life Support Provider/Instructor (CPR-P/I)

Advanced Cardiac Life Support Provider (ACLS)

Pediatric Advanced Life Support Provider (PALS)

Please contact us if we may be of further assistance. A student will have 4 years from the start date of his/her initial advanced EMSP coursework to complete all EMSP major requirements. The exception to this rule is an individual who elects to exit the program with a successful EMT-Intermediate State Certification and/or National Registry and later elects to return to complete the EMT-Paramedic coursework. In this event, the student may be re-admitted providing: there is sufficient clinical space, the student passes re-entry criteria which will be based on skills and written examination results, and the student satisfies additional admission criteria that may be implemented subsequent to this publication. Any student changing from AAS to the certification program will be subject to the current curriculum.

Amarillo College

Established 1929

Emergency Medical Services Professions

Degree Plan for Associate in Applied Science (MAJOR CODE – EMSP.AAS)

This program is designed for students who wish to earn an A.A.S. degree in addition to completing the academic, clinical, and field internship requirements necessary to sit for the National Registry of Emergency Medical Technicians' Paramedic (NREMT-P) registry exam. Successful completion of selected coursework also satisfies the academic, clinical, and field internship preparatory requirements for prospective certification or licensure with the State of Texas as an Emergency Medical Technician – Basic (EMT-B), EMT – Intermediate (EMT-I), EMT – Paramedic (EMT-P), or Licensed Paramedic (L.P.).

A grade of “C” or higher is required for satisfactory completion of all courses in this curriculum.

EMSP 1501 and EMSP 1163 are open-admission courses; satisfying admission requirements to Amarillo College will satisfy admission requirements to these courses. A student seeking admission into any EMSP course other than EMSP 1501 and EMSP 1163 must file a specific program application form and/or complete additional course/program admission requirements prior to course enrollment.

Semester Hours

GENERAL EDUCATION REQUIREMENTS 26

MATH: 1332 or any Math Course from the approved list* 3

BIOL 2401: Human Anatomy and Physiology I* 4

BIOL 2402: Human Anatomy and Physiology II* 4

SPCH: Any SPCH Course from the approved list 3

ENGL 1301: Freshman Composition 3

PSYC: Any PSYC Course from the approved list 3

HUMANITIES: Any from approved list 3

ELECTIVE: Cumulative 3 hrs: any academic course(s) from the College Catalog 3

MAJOR REQUIREMENTS 40

EMSP 1501: Emergency Medical Technician-Basic 5

EMSP 1163: Clinical-Emergency Medical Technology 1

EMSP 1438: Introduction to Advanced Practice 4

EMSP 1455: Trauma Management 4

EMSP 1456: Patient Assessment and Airway Management 4

EMSP 1149: Pre-Hospital Trauma Life Support 1

EMSP 2266: Practicum I 2

EMSP 2434: Medical Emergencies 4

EMSP 2430: Special Populations 4

EMSP 2444: Cardiology 4

EMSP 2135: Advanced Cardiac Life Support 1

EMSP 2267: Practicum II 2

EMSP 1147: Pediatric Advanced Life Support 1

EMSP 2348: Emergency Pharmacology 3

66

* Note: The Math and A/P courses must be successfully completed prior to registration for EMSP 2434, 2430, 2444

Amarillo College

Established 1929

Emergency Medical Services Professions

|AAS DEGREE CURRICULUM |Rubric |Lec Hrs |Lab Hrs |Ext Hrs |Cont Hrs |Cred Hrs |

|1st Fall Semester | | | | | | |

|EmergencyMedicalTechnician-Basic |EMSP 1501 |4 |4 | |128 |5 |

|Clinical-EmergencyMedicalTechnology |EMSP 1163 | | |3 |48 |1 |

|1332orAnyMathCourseFromCollegeList |MATH |3 | | |48 |3 |

|HumanAnatomyAndPhysiology I |BIOL 2401 |3 |3 | |96 |4 |

| |TOTAL HRS |10 |7 |3 |320 |13 |

|1st Spring Semester | | | | | | |

|IntroductionToAdvancedPractice |EMSP 1438 |3 |3 | |96 |4 |

|TraumaManagement |EMSP 1455 |3 |3 | |96 |4 |

|PatientAssessment&AirwayManagement |EMSP 1456 |3 |3 | |96 |4 |

|Pre-HospitalTraumaLifeSupport |EMSP 1149 |1 |1 | |32 |1 |

|HumanAnatomyAndPhysiology II |BIOL 2402 |3 |3 | |96 |4 |

| |TOTAL HRS |13 |13 | |416 |17 |

|12 Week Summer Term | | | | | | |

|Practicum/FieldExperience-EMT |EMSP 2266 | | |18 |288 |2 |

|AnySPCHCourseFromApprovedList |SPCH |3 | | |48 |3 |

|Any Humanities form the approved list |Humanities |3 | | |48 |3 |

| |TOTAL HRS |6 | |18 |384 |8 |

|2nd Fall Semester | | | | | | |

|MedicalEmergencies |EMSP 2434 |3 |3 | |96 |4 |

|SpecialPopulations |EMSP 2430 |3 |3 | |96 |4 |

|Cardiology |EMSP 2444 |3 |3 | |96 |4 |

|AdvancedCardiacLifeSupport |EMSP 2135 |1 |1 | |32 |1 |

|FreshmanComposition |ENGL 1301 |3 |3 | |48 |3 |

|PediatricAdvancedLifeSupport |EMSP 1147 |1 |1 | |32 |1 |

| |TOTAL HRS |14 |14 | |400 |17 |

|2nd Spring Semester | | | | | | |

|Practicum/FieldExperience-EMT |EMSP 2267 | | |18 |288 |2 |

|AnyPSYCCourseFromPage35 |PSYC |3 | | |48 |3 |

|Emergency Pharmacology |EMSP 2348 |3 | | |48 |3 |

|Elective,Cumulative3HrsAnyAcademicCourse |ELECTIVE |3 | | |48 |3 |

| |TOTAL HRS |9 | |18 |432 |11 |

| | | | | | | |

|GRAND TOTALS: |52 |34 |39 |1952 |66 |

Amarillo College

Established 1929

Emergency Medical Services Professions

Degree Plan for Certificate of Completion (MAJOR CODE – EMSP.CERT)

WARNING: This is a THEA vulnerable certificate. Enrollment in a degree level course outside the certificate will subject a student to mandatory testing/remediation as prescribed by THEA regulations.

This program is designed for students who wish to earn a Certificate of Completion in addition to completing the academic, clinical, and field internship requirements to sit for the National Registry of Emergency Medical Technicians Paramedic (NREMT-P) registry examination. Successful completion of all course work as well as successful completion of the National registry exam will satisfy the requirements of the Texas Department of State Health Services for registry as a Certified Paramedic (EMT-P.) Successful completion of selected coursework also satisfies the academic, clinical, and field internship preparatory requirements for prospective certification with the State of Texas as an Emergency Medical Technician-Basic (EMT-B) or EMT-Intermediate (EMT-I).

A grade of “C” or higher is required for satisfactory completion of all courses in this curriculum.

EMSP 1501 and EMSP 1163 are open-admission courses; satisfying admission requirements to Amarillo College will satisfy admission requirements to these courses. A student seeking admission into any EMSP Course other than EMSP 1501 and EMSP 1163 must file a specific program application form and/or complete additional course/program admission requirements prior to course enrollment.

Semester Hours

GENERAL EDUCATION REQUIREMENTS 11

MATH : 1332 or any Math Course from the approved list* 3

BIOL 2401: Human Anatomy and Physiology I* 4

BIOL 2402: Human Anatomy and Physiology II* 4

MAJOR REQUIREMENTS 36

EMSP 1501: Emergency Medical Technician-Basic 5

EMSP 1163: Clinical-Emergency Medical Technology 1

EMSP 1438: Introduction to Advanced Practice 4

EMSP 1455: Trauma Management 4

EMSP 1456: Patient Assessment and Airway Management 4

EMSP 1149 PreHospital Trauma Life Support 1

EMSP 2266: Practicum I 2

EMSP 2434: Medical Emergencies 4

EMSP 2430: Special Populations 4

EMSP 2444: Cardiology 4

EMSP 2135: Advanced Cardiac Life Support 1

EMSP 2267: Practicum II 2

EMSP 1147: Pediatric Advanced Life Support 1

EMSP 2348: Emergency Pharmacology 3

51

* Note: The Math and A/P courses must be successfully completed prior to registration for EMSP 2434, 2430, 2444

Amarillo College

Established 1929

Emergency Medical Services Professions

|CERTIFICATE CURRICULUM |Rubric |Lec Hrs |Lab Hrs |Ext Hrs |Cont Hrs |Cred Hrs |

|1st Fall Semester | | | | | | |

|EmergencyMedicalTechnician-Basic |EMSP 1501 |4 |4 | |128 |5 |

|Clinical-EmergencyMedicalTechnology |EMSP 1163 | | |3 |48 |1 |

|1332orAnyMathCourseFromCollegeList |MATH |3 | | |48 |3 |

|HumanAnatomyAndPhysiology I |BIOL 2401 |3 |3 | |96 |4 |

| |TOTAL HRS |10 |7 |3 |320 |13 |

|1st Spring Semester | | | | | | |

|IntroductionToAdvancedPractice |EMSP 1438 |3 |3 | |96 |4 |

|TraumaManagement |EMSP 1455 |3 |3 | |96 |4 |

|PatientAssessment&AirwayManagement |EMSP 1456 |3 |3 | |96 |4 |

|Pre-HospitalTraumaLifeSupport |EMSP 1149 |1 |1 | |32 |1 |

|HumanAnatomyAndPhysiology II |BIOL 2402 |3 |3 | |96 |4 |

| |TOTAL HRS |13 |13 | |416 |17 |

|12 Week Summer Term | | | | | | |

|Practicum |EMSP 2266 | | |18 |288 |2 |

| |TOTAL HRS | | |18 |288 |2 |

|2nd Fall Semester | | | | | | |

|Pediatric Advanced Life Support |EMSP 1147 |1 |1 | |32 |1 |

|MedicalEmergencies |EMSP 2434 |3 |3 | |96 |4 |

|SpecialPopulations |EMSP 2430 |3 |3 | |96 |4 |

|Cardiology |EMSP 2444 |3 |3 | |96 |4 |

|AdvancedCardiacLifeSupport |EMSP 2135 |1 |1 | |32 |1 |

| |TOTAL HRS |11 |11 | |352 |14 |

|2nd Spring Semester | | | | | | |

|Practicum/FieldExperience-EMT |EMSP 2267 | | |18 |288 |2 |

|Emergency Pharmacology |EMSP 2348 |3 | | |36 |3 |

| |TOTAL HRS | | |18 |336 |5 |

| | | | | | | |

|GRAND TOTALS: |37 |31 |39 |1696 |51 |

Note to currently certified EMSP degree candidates:

Credit by exam is being offered for those currently certified at or above the level of EMT Basic.

If you would like to earn college credit toward a degree call the EMSP office for details.

The cost of processing the paper work is $15.00 per course. Each candidate must pass the final exam for a given course to be eligible of credit and each candidate must have at least one Amarillo College credit course on a transcript before the credit by exam course will show up. Note: You must complete at least 18 semester credit hours at Amarillo College to earn a degree.

Further information:

806 354-6077

criteria for admission into the

basic EMSP PROGRAM

Admission to the EMT-Basic Classes

1. The applicant must satisfy the general admission requirements to Amarillo College.

2. Proof of compliance with the following immunization requirements prior to beginning any clinical rotations of the course:

The law requires that colleges in Texas who have health career programs require the students enrolled in those programs to obtain the following immunizations:

1. Tetanus/Diphtheria (must have had ONE dose within the past 10 years).

2. Measles (those born since January 1, 1957 must have TWO doses since 12 months of age).

3. Mumps (those born since January 1, 1957 must have at least ONE dose since 12 months of age).

4. Yearly tuberculin skin test

5. Hepatitis B (a THREE dose inoculation series).

6. Varicella ( a two dose inoculation series).

3. The student is required to complete a criminal background check prior to reporting to any clinical rotations of this course. The criminal background check is required by the Joint Commission on Accreditation of Hospital organizations (JCAHO) and based on JCAHO Standard H.R. 1.20. The student will be required to submit your name and social security number to preCheck, INC. and will be assessed a fee for the report payable to preCheck, INC. at the time of the application. The student will need to begin this process within the first week of class. If any information regarding your past legal history that is unacceptable by the Hospitals according to JCAHO Standard H.R. 1.20, you will be denied permission to continue in the course and will forfeit any tuition and fees previously paid to Amarillo College.

NOTE: The applicant must be 18 years of age and have earned a high-school diploma or a GED certificate within one year of EMT-Basic course completion date to sit for the National Registry of Emergency Medical Technicians Basic certification examination.

CRITERIA FOR ADMISSION INTO THE

advanced EMSP Curriculum

Admission to the EMT-Intermediate Classes

1. The applicant must hold current certification as a Texas EMT-Basic or National Registry EMT-B and maintain that certification throughout their EMSP curriculum.

2. The applicant must have earned a high-school diploma or a GED certificate and satisfy the general admission requirements to Amarillo College.

3. The following documentation must be on file with the EMSP Program Director:

a. A completed application packet for the EMSP Program

b. All high school and college transcripts

c. Documentation of high school and college honors

d. Signed waiver of release of liability

e. Documentation showing you have received this criteria for admission into the EMSP Program.

f. Proof of compliance with the following immunization requirements:

The law requires that colleges in Texas who have health career programs require the students enrolled in those programs to obtain the following immunizations:

1. Tetanus/Diphtheria (must have had ONE dose within the past 10 years).

2. Measles (those born since January 1, 1957 must have TWO doses since 12 months of age).

3. Mumps (those born since January 1, 1957 must have at least ONE dose since 12 months of age).

4. Yearly tuberculin skin test

5. Hepatitis B (a THREE dose inoculation series).

6. Varicella ( a two dose inoculation series

4. The applicant must have completed the THEA or THEA equivalent. Call 371-5445 for information.

5. If the applicant is required to complete any remediation as a result of the THEA, applicant cannot be considered for admission until remediation schedule is in place.

Depending on the applicants THEA Score, Math remediation may be required before enrolling in the required Math course.

6. The applicant must have a personal interview with a full-time EMSP faculty member.

7. The applicant must earn sufficient admission points to be placed on the class roster. The procedures for receiving admission points will be described in the admission process document.

8. The student is required to complete a criminal background check prior to reporting to clinical. The criminal background check is required by the Joint Commission on Accreditation of Hospital organizations (JCAHO) and based on JCAHO Standard H.R. 1.20. The student will be required to submit your name and social security number to preCheck, INC. and a fee for the report payable to preCheck, INC. at the time of the application. If any information regarding your past legal history that is unacceptable by the Hospitals according to JCAHO Standard H.R. 1.20, you will be denied permission to continue in the course and will forfeit any tuition and fees previously paid to Amarillo College.

9. The applicant must be able to fully participate in all clinical activities in such a way as to not pose a risk to the safety of themselves, the patient, or clinical personnel. A medical physical exam may be required.

criteria for admission into the

advanced EMSP Curriculum

Admission to the Paramedic/EMT-Paramedic Classes

The applicant must complete all prerequisite course work with no lapse in time

OR

1. Hold current certification as a Texas EMT-Intermediate or National Registry EMT-Intermediate and document Credit By Examination for all prerequisite course work.

2. The applicant must have earned a high-school diploma or a GED certificate and satisfy the general admission requirements to Amarillo College.

3. The following documentation must be on file with the EMSP Program Director:

a. A completed application packet for the EMSP Program

b. All high school and college transcripts

c. Documentation of high school and college honors

d. Signed waiver of release of liability

e. Documentation showing you have received this criteria for admission into the EMSP Program.

f. Proof of compliance with the following immunization requirements:

The law requires that colleges in Texas who have health career programs require the students enrolled in those programs to obtain the following immunizations:

1. Tetanus/Diphtheria (must have had ONE dose within the past 10 years).

2. Measles (those born since January 1, 1957 must have TWO doses since 12 months of age).

3. Mumps (those born since January 1, 1957 must have at least ONE dose since 12 months of age).

4. Yearly tuberculin skin test

5. Hepatitis B (a THREE dose inoculation series).

6. Varicella ( a two dose inoculation series).

4. The applicant must have completed the THEA or THEA equivalent. Call 371-5445 for information.

5. If the applicant is required to complete any remediation as a result of the THEA, applicant cannot be considered for admission until remediation schedule is in place.

Depending on the applicants THEA Score, Math remediation may be required before enrolling in the required Math course.

6. The applicant must have a personal interview with a full-time EMSP faculty member.

7. The applicant must earn sufficient admission points to be placed on the class roster. The procedures for receiving admission points will be described in the admission process document.

8. The student is required to complete a criminal background check prior to reporting to clinical. The criminal background check is required by the Joint Commission on Accreditation of Hospital organizations (JCAHO) and based on JCAHO Standard H.R. 1.20. The student will be required to submit your name and social security number to preCheck, INC. and a fee for the report payable to preCheck, INC. at the time of the application. If any information regarding your past legal history that is unacceptable by the Hospitals according to JCAHO Standard H.R. 1.20, you will be denied permission to continue in the course and will forfeit any tuition and fees previously paid to Amarillo College.

9. The applicant must be able to fully participate in all clinical activities in such a way as to not pose a risk to the safety of themselves, the patient, or clinical personnel. A medical physical exam may be required.

10. Math, Anatomy and Physiology I and II must be completed prior to admission to the Paramedic completion semesters.

Admission Process for the

advanced EMSP Curriculum

1. The applicant will complete and submit an application portfolio that will include:

a. A completed EMSP application form.

b. Amarillo College Student Release and Waiver of Liability form.

c. Copies of High School (if claiming points for tech-prep, honors…) and College transcripts.

d. Results of THEA or THEA equivalent.

If any of the test scores are deficient as determined by the counseling center, the applicant will be required to have a remediation schedule in place prior to consideration of their application.

The completed application portfolio must be submitted to the EMSP office no later than the October 15th immediately preceding the anticipated January start date of EMSP coursework beyond the introductory EMSP course work.

2. From October 15th through November 1st of each year, the EMSP office will review all applicants that have submitted timely and complete portfolios. During the review process, points earned by each applicant will be totaled. The applicants with the highest total points will fill the allotted openings for students to be admitted into the advanced EMSP class that will begin in the following January.

points are earned by:

A. Completion of required EMSP General Education courses as listed in the general catalogue:

Each "A" earns 10 points

Each "B" earns 6 points

Each "C" earns 2 points

Each "D" earns 0 points

Each "F" earns -2 points

B. Completion of required EMSP Related and Elective courses as listed in the general catalogue:

Passing grade for Human A&P II 10 points

Each "A" earns 6 points

Each "B" earns 4 points

Each "C" earns 2 points

Each "D" earns 0 points

Each "F" earns 2 points

C. Completion of any college degree or certificate earned from an accredited institution of higher learning:

Any appropriate, health-care related

certificate earns 10 points

Any associates degree earns 20 points

Any Bachelor's or higher degree earns 30 points

D. High School Honors (Documentation Required)

Valedictorian earns 10 points

Salutatorian earns 8 points

National Honor Society earns 5 points

Tech-Prep High School Graduates 10 points

E. EMS related service and experience

Length of continuous EMS certification:

12 years or more 15 points

8 years 10 points

4 years 5 points

Volunteer provider for: (Documentation Required)

5 years or more 30 points

2 years 15 points

At least 1 year 5 points

Paid provider for: (Documentation Required)

5 years or more 30 points

2 years 15 points

At least 1 year 5 points

3. During November of the same year, the EMSP office will notify, by letter, each applicant who submitted a portfolio as to the total points they earned. Also, the letter will give the ranking of the applicant within the total applicant pool and the number of applicants to be admitted. If the applicant ranks within the highest number of applicants to be admitted that year, he or she will receive an appointment to begin the advanced EMSP program with the start of the January class.

The applicant will be given a two week period in which to accept their class appointment.

If confirmation is not received in this two-week period the applicant will forfeit their position in the class.

If the applicant ranks beyond the allotted number he or she will be advised to reapply for the following year.

Such a re-application must be made in writing through a letter to the EMSP Program Director postmarked no later than the last day of August of the following calendar year. Following this date, all portfolios of applicants not requesting re-application will be discarded.

4. If an applicant is selected and declines the position in the class he/she will forfeit their position in the class and will be required to follow the process for re-application if they wish to be considered for the class in the following year. The forfeited position will be awarded to the next highest qualified applicant.

Name _______________________

Date ________________________

Amarillo College

Division of Allied Health

Emergency Medical Services Professions

Admission Packet Work Sheet

1. ( Completed application on file in the office of the program director.

2. ( Copy of High School (if required) and College transcripts on file in the office of the program director.

3. ( Signed waiver of liability form on file in the office of the program director.

4. ( Documentation of proof of compliance with immunization requirements on file in the office of the program director.

5. ( Completion of the THEA or THEA equivalent (call 371-5445 for information).

6. ( Copies of any High School/College Honors documentation filed in the office of the program director.

7. ( Copy of admission criteria notification form filed in the office of the program director.

8. ( Personal interview with a full-time EMSP program faculty member. (This interview is to be scheduled after you have completed all of the above requirements).

Amarillo College

Division of Allied Health

Emergency Medical Services Professions

NAME OF APPLICANT:

Last First M.I.

SOCIAL SECURITY NUMBER: - -

BY MY SIGNATURE ON THIS DOCUMENT, I AcKNOWLEDGE THAT I HAVE BEEN PROVIDED WRITTEN DOCUMENTATION FOR ADMISSION INTO THE ADVANCED EMSP PROGRAM AT AMARILLO COLLEGE.

IN PARTICULAR, I HAVE RECEIVED EACH OF THE FOLLOWING:

1. LIST OF SPECIFIC CRITERIA FOR ADMISSION INTO THE EMSP PROGRAM.

2. STEP-BY-STEP DESCRIPTION OF THE PROCESS USED TO MAKE APPLICANT SELECTION FOR THE ADVANCED EMSP PROGRAM TO INCLUDE NOTIFICATION PROCEDURES.

I UNDERSTAND THAT CERTAIN PROCEDURES (e.g., deadlines) within the selection process may be subject to change, however, the specific criteria for admission that i have been provided is not subject to change relative to my application.

Signature of applicant signature of witness

DATE DATE

AMARILLO COLLEGE DIVISION OF ALLIED HEALTH

STATE OF TEXAS §

§ RELEASE AND WAIVER OF LIABILITY

COUNTY OF POTTER §

AGREEMENT OF RELEASE made this day between AMARILLO JUNIOR COLLEGE DISTRICT ("Amarillo College") and ("Student").

Name of Student

In consideration of Student being permitted to enroll at Amarillo College in the Emergency Medical Services Professions program and the acknowledgement of Student of the following facts:

1. That Student will be required, as part of the normal educational process towards Student's degree to be placed in a teaching environment including, but not limited to, local medical institutions, offices of local practitioners, ambulances, medical laboratories, and other environment (hereinafter called medical affiliates), all of which are affiliated with Amarillo College for these purposes and that while in these medical affiliates, Student may be exposed to conditions which could cause bodily injury and/or death and may be exposed to patients afflicted with fatal or potentially fatal diseases processes which may be of a contagious nature; and,

2. That Student will be first provided as part of the normal educational process toward Student's degree or certificate of completion with detailed information about the nature, risks and preventive measures related to communicable diseases of a fatal or potentially fatal nature prior to assignment of Student; and,

3. That Student could be exposed to high risk toxic substances in the medical affiliates, but will be first provided with information concerning prevention from becoming ill with same.

Student does hereby:

1. Authorize Amarillo College officials to place Student into the respective medical affiliates as they deem necessary for the successful completion of Student's specific educational program;

2. Release, waive, and covenant not to sue Amarillo College, its officers, agents, employees, and persons or entities acting together with Amarillo College in its educational programs (hereinafter collectively called Releasees) from all liability to Student for any and all loss or damage, and any claims or demands whatsoever therefore on account of injury to the person or property or resulting in death of Student or emanating from exposure to said disease processes and toxic substances, or any of these, whether caused by the negligence of Releasees or otherwise while the Student is on or within any of the medical affiliates;

3. Indemnify and hold harmless Releasees from any loss, liability, damage or cost that Student may incur due to the presence of Student in or upon any of the medical affiliates or in any way observing for any purpose or participating in the educational process in said medical affiliates; and,

4. Assumes full responsibility, including any medical treatment and cost thereof, for any and all risks of exposure to communicable diseases, bodily injury, death or property damage due to negligence of Releasees or otherwise, due to Student participation in the normal educational process in the medical affiliates, or being transported to and from said affiliates.

The UNDERSIGNED expressly acknowledges and agrees that the activities described above could be dangerous and involve the risk of illness, injury and/or death and/or contracting fatal or potentially fatal disease processes and exposure to high risk toxic substances.

The UNDERSIGNED expressly agrees that the foregoing Release, Waiver, and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the Laws of the State of Texas and if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

The UNDERSIGNED has read and voluntarily signed the Release and Waiver of Liability and Indemnity Agreement, and agrees that no oral representations, statements or inducements apart from the foregoing written Agreement have been made.

-------------------------------------------------------------------------------------------------------------------------------------------------------

I have read this document. I understand it is a release of all claims. I understand I assume all risks inherent in the educational process and clinical experience conducted in the medical affiliates of Amarillo College as part of my progressing toward a degree as set out above.

I voluntarily sign my name evidencing my acceptance of the above provisions.

Dates this day of 20

Signed:

Full Legal Name of Student

Amarillo College

Division of Allied Health

Emergency Medical Services Professions

PROGRAM APPLICATION

instructions: Please PRINT or TYPE all information on this form (both sides). Complete ALL items. Information must be current and as accurate as possible. If the applicant's name, mailing address, or phone numbers change after this application has been filed, it is the responsibility of the applicant to update the appropriate information with the EMSP Program Director IMMEDIATELY. Failure to maintain a current application form will jeopardize the validity of the application.

NAME IN FULL:

First Middle Last

Home Address:

Number & Street City State Zip Code

Home Phone: ( ) - Business Phone: ( ) -

Social Security Number: - - Date of Birth: - -

(optional information)

EMT-Basic Course: School Location Date Completed

City/School Name State

Please include a copy of your current texas EMT-Basic certificate

Person To Notify In Case Of Emergency: Phone: ( ) -

Circle all Degree(s) Held: G.E.D High School Diploma Certificate

Associates Bachelor's Master's

Other:

Have you ever been convicted of a felony or misdemeanor more serious than a Class "C" Misdemeanor?

Yes No If yes, explain the details using an attached page and note current civil rights status.

Admission into the clinical portion of this program requires that you be able to fully participate in all clinical activities in such a way so as not to pose a risk to the safety of the patient or clinical personnel. Can you satisfy such a requirement? Yes No

important - please read the following statements carefully.

sign to signify that you have read and understand each of the statements.

Your application is not complete until you have fulfilled each of the following requirements:

1. Completed application on file in the office of the program director.

2. Copy of High School (if required) and College transcripts on file in the office of the program director.

3. Signed waiver of liability form on file in the office of the program director.

4. Documentation of proof of compliance with immunization requirements on file in the office of the program director.

5. Completion of the THEA or THEA equivalent (call 371-5445 for information).

6. Copies of any High School/College Honors documentation filed in the office of the program director.

7. Copy of admission criteria notification form filed in the office of the program director.

8. Personal interview with a full-time EMSP program faculty member. (This interview is to be scheduled after you have completed all of the above requirements).

I have read and understand requirements 1-8 listed above:

Signature of applicant date

Signature of witness date

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