EMT PROGRAM APPLICATION

EMT BASIC PROGRAM

PROGRAM ADMISSION

Disqualification

Tennessee EMS Regulations precludes admission of students to EMT certification courses with a felony on their record without Bureau approval.

The State of Tennessee EMS Board individually reviews the applications for certification of those with misdemeanor convictions after a background investigation by division staff. They may choose not to certify these individuals. These applications are handled on a case‐by‐case basis, after course completion. There is no mechanism to pre‐review the circumstance to determine certification eligibility.

Students who are charged or convicted of a felony or misdemeanor involving moral turpitude while in the program may be suspended or dismissed from the program.

Former Name (If Applicable)

EMT CERTIFICATION PROGRAM

Program Description

The EMT Certification Program is entry‐level training for the professional pre‐hospital care provider. Students who successfully complete the program are eligible to take the National Registry of EMTs cognitive exam, which isrequired for State of Tennessee EMT licensure.

Admission Requirements

Minimum Age:	18 years of age
Background Check:	Complete required background check.

Field Experience Requirements

The EMT course includes lecture, lab, and field experience. The following items are required to schedule and participate in the field experience component of the course:

TB Testing and Vaccinations:	Submit proof of vaccinations and TB test results before the first class session.
Physical Exam:	Documentation from a physician for fitness to participate in the program before first class session. Complete State Form PH-0130
Liability Insurance:	Students are assessed the fee that is included in the program tuition.
Health Insurance:	Provide proof of personal health care insurance.
CPR:	Successful completion of the Basic Life Support for the Health Care Provider component of the course.

Anticipated Course Expenses

Costs for EMT Basic Certification:

Tuition
Background check, TB Skin Test only, Drug Screen
Textbooks, uniform, medical equipment
Clinical uniform shirt
Medical liability insurance

$2200.00

Costs for EMT Basic Certification

$2200.00

PROGRAM OF APPLICATION

Please fill out this form in its entirety.

Name*

First Name Middle Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Are you a military service veteran?

YesNo

Have you ever been convicted of a felony?*

YesNoOther

Have you ever been convicted of a misdemeanor?*

YesNo

Completion of this form and minimum program requirements does not constitute admission to the program. Applicants will be notified by letter when they are accepted into the program.

Community Health Care is committed to continuing affirmative action and equal opportunities of access to employment and education and thus does not discriminate against current or potential employees or students on the basis of race, color, religion, sexual orientation, national origin or ancestry, age, disability, sex, military status or status as a veteran. It is also the intent of Community Health Care to comply with appropriate federal and state laws, rules and regulations and to give special attentionto increasing the participation of minorities, women, persons with a disability and disabled veterans in all levels of the program. It is also the intent to ensure that its environment is free from harassment or intimidation of any kind.

I certify that the information provided on this application is complete and accurate in every respect. I understand that falsifying any of this application may result incancellation of admission.

Date*

BACKGROUND CHECK AND CONVICTION OF CRIME ACKNOWLEDGEMENT

I understand and acknowledge that CHC901 LLC. DBA Community Health Care (CHC) may develop or obtain one or more criminal background checks (“CBC”) pertaining to me. The CBC may be used for evaluation of my eligibility for entry into programs of CHC, and eligibility for one or more clinical/practicum/internship training requirements with CHC or third‐party organizations. I understand and acknowledge that the CBC may contain information concerning my criminal background. In all cases,all expenses associated with the CBC are to be my responsibility. If the results of the CBC are not deemed acceptable by CHC, or if information received indicates that I have provided false or misleading statements, have omitted required information or in any way am unable to meet the requirements for completion of the program, my admission may be denied or rescinded, and/or I may be disciplined or dismissed. I further understand and acknowledge that if, while I am a student, I am convicted of a crime of any type, other than a minor traffic violation, I must report the offense to the Dean writing within 10 days of conviction (conviction includes plea arrangements, guilty pleas, pleas of no contest, findings of guilt, etc.).

Student Name*

First Name Last Name

Date*

STUDENT INFORMATION FORM

Name*

First Name Middle Name Last Name

Former Name (If Applicable)

Birthday*

High School Diploma or GED: *

Please respond to the following questions to determine qualification for certification under OAC4765‐8‐01‐A:

1. Are you at least 18 years old?*

YesNo

2. Have you ever been adjudicated mentally incompetent by a court of law?*

YesNo

3. Have you ever been convicted of, pled guilty to, had a judicial finding of guilt for or had a judicial finding of eligibility for treatment/interventions in lieu of conviction for; or are you currently under indictment for any of the following: any felony; a misdemeanor committed in the course of practice; a misdemeanor involving moral turpitude; a violation of any federal, state, county, or municipal narcotics law or controlled substance law; an act committed in another state?*

YesNo

4. Do you currently engage in the illegal use or illegal acquisition of controlled substances, alcohol or other habit‐forming drugs or chemical substances?*

YesNo

5. Have you ever committed fraud or material deception in applying for or obtaining a certificate to practice in a healthcare profession?*

YesNo

6. Have you been convicted, in this state or another state, of providing emergency medical services or representing yourself as an EMS provider without a license or certificate, or a similar crime directly related to the profession of EMS?*

YesNo

7. If you are or have been certified or licensed as an EMS provider in this state or another state, is your certificate or license currently on probationary status, or has it been suspended or revoked by the board or the EMS certifying licensing entity in another state?*

YesNo

The above information is true and correct to the best of my knowledge. I authorize the release of my state examination scores to the State of Tennessee and Community Health Care. I understand that supplying false information may mean dismissal from all EMT classes, and reporting to the State of Tennessee, Department of Health Emergency Medical Services Bureau.

Applicant Signature*

Clear

Date*

SELF EVALUATION FORM

Name*

First Name Last Name

Date*

Please answer the following questions, choosing the answer that best describes your current circumstances.

Please identify your current EMT certification status:*

I do not hold any EMT certificationsI am a State of Tennessee‐certified First ResponderI am EMT certified in a state other than Tennessee

Level of Certification:

Please identify any of the following health care licenses you may possess:*

I do not hold any other health care licensesI am a registered nurse or licensed practical nurseI am a respiratory therapistI hold another health care professional license

Professional License:*