EMT-Intermediate - Anne Arundel Community College

ANNE ARUNDEL COMMUNITY COLLEGE
EMERGENCY MEDICAL TECHNICIAN - INTERMEDIATE PROGRAM APPLICATION
FALL 2014
Application Deadline: March 15, 2014
Re-applicant: _____Yes _____ No
COLLEGE ID#
NAME:
Last
First
Maiden
STREET ADDRESS
CITY
STATE
ZIP
COUNTY of Residence
AACC EMAIL ADDRESS REQUIRED (This is the only acceptable email address for communication)
Email address:
@mymail.aacc.edu
Home Phone:
Work Phone:
Cell Phone:
Last digits of Social Security #
(PRINT CLEARLY)
ACADEMIC REQUIREMENTS AND PREREQUISITES:
High School attended or State of GED:
ENGLISH 111 eligible: YES

Graduated Month/Year:
NO

or MAT 005 – Arithmetic (1 equivalent hour) Grade:
Arithmetic Placement Test SCORE:
Complete by application deadline. This is not the same as the Mathematics Placement.
Call if you have questions 410-777-7070.
Health Form Completed Within 1 Year of Entering Program?
Course
Grade
Received
YES
College or Academy where course was completed.
Must submit official TR if other than AACC
NO
Basic Certification
Expiration Date
EMT-BASIC
American Heart Association CPR certification
for Healthcare Providers
Date Certified:
Attach a copy of your current certification card
EMS Affiliation:
EMS Officer’s Name:
EMT-B – Number of Patient Contact Hours within One Year:
(Must supply documentation/verification from EMS Officer)
I understand that acceptance into the EMT-Intermediate program is contingent on the satisfactory results of the Criminal
Background Check, and satisfactory completion of the Health Examination Record. I certify that the information on the
application is true and accurate to the best of my knowledge. Falsification or misrepresentation of my address and/or grades
may result in being denied admission to the program.
Student Signature (Required)
Date
NOTE: A copy of your MD driver’s license or government issued photo I.D. must be attached to this application
1
BACKGROUND INFORMATION
YES
NO




QUESTION
Submit explanation of questions for which you answer “yes” in a sealed
envelope. Attention: Tammie Neall, FLRS 100
Were you ever disciplined for any academic or conduct issue by any
college, university, or any other educational institution such as, but not
limited to, probation, dismissal, suspension, disqualification, or imposition of
a failing grade as a disciplinary sanction? If your answer is yes to any
question herein provide a written explanation and all relevant documents
and information.
Have you ever been convicted of a crime, driving while intoxicated or
impaired (either by alcohol or drugs), traffic violation resulting in points on
your licenses, and/or are there any pending charges? If your answer is yes
to any question herein provide a written explanation and all relevant
documents and information.
Have you ever surrendered a professional or drivers license or had such a
license, certification, vehicle registration, or clinical privileges revoked,
suspended, or in any way restricted by an institution, state, or locality? If
your answer is yes to any question herein provide a written explanation and
all relevant documents and information.
Have you ever been convicted of a felony or misdemeanor and/or are there
any pending charges? If your answer is yes to any question herein provide
a written explanation and all relevant documents and information.
NOTE: Licensing boards for certain health care occupations, including EMT, may deny, suspend, or revoke a license or may
deny the individual the opportunity to sit for an examination even if the individual has completed all program course work, if
it is determined that an applicant has a criminal history or is convicted or pleads guilty or nolo contendere to a felony or other
serious crime. I certify that the information on this application is true and accurate to the best of my knowledge.
Falsification or misrepresentation of any information on this application may result in being denied admission to the
program. I understand that final acceptance into the EMT program shall be contingent upon satisfactory completion of a
criminal background check and satisfactory completion of a health examination record.
Signature:
Date:
*NOTE: First consideration for selection will be given to candidates whose residence address is in
Anne Arundel County for at least three (3) months prior to the application deadline date.
Notice of Nondiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call
Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations.
Requests for sign language interpreters, alternative format books or assistive technology require 30 days’ notice. For
information on AACC’s compliance and complaints concerning discrimination or harassment, contact Kelly Koermer, J.D.,
federal compliance officer, at 410-777-2607 or Maryland Relay 711.
NOTE: Official transcripts are to be received by AACC in the sending
institution’s original sealed envelope.
2
ANNE ARUNDEL COMMUNITY COLLEGE
Emergency Medical Technician Department
VERIFICATION OF PATIENT CONTACT HOURS
(Please check one)

ALS

BLS
Name:
Social Security #
Affiliation #
Affiliation Name:
Years as an EMT-Basic:
Number of Patient Contacts as an EMT-Basic
Company Verification
To be completed by the company senior EMS officer.
I verify that the candidate named in this form have completed the above stated number of ambulance calls. This
company approves of this individual’s participation in EMS training.
Signature
Date
Print Name
Title
Student Signature
This form must be submitted by May 3, 2014
3
Recommendation Form
Emergency Medical Technician-Intermediate Program
School of Health Professions, Wellness, and Physical Education
Anne Arundel Community College
101 College Parkway
Arnold, MD 21012
For the Classes Beginning fall 2014
Instructions for the Applicant:
Type or print in black ink your name and the name, title, and affiliation of the person familiar with your professional
or academic performance to whom you are forwarding this evaluation form.
Applicant's Name
Last
First
Middle
Address
Telephone number
Evaluator's Name
Title
Last
First
Institution
By signing below, I hereby give permission to the Emergency Medical Technician Program, Anne Arundel
Community College, to contact the above agency or individual if additional information is needed.
In accordance with federal regulations, materials in student files, such as letters of recommendation, are open to
inspection upon request, unless the student has waived the right of access in advance. Please indicate your wish
by completing and signing the statement below.
I (circle one) DO, DO NOT waive my right to review this letter.
Applicant's Signature
Date
***********
Instructions for the Evaluator:
Please complete this form in its entirety and return it to the applicant in a sealed envelope. If desired, you
may return the letter of recommendation directly to: Tammie Neall, Admissions/Advisement Coordinator,
Anne Arundel Community College, 101 College Parkway, Arnold, MD 21012. You may attach an additional
sheet of paper if the space available on this form is insufficient for your comments.
The deadline for receipt of all application materials is May 3, 2014 for fall admission. Your cooperation in
returning this form before this date will help ensure that the applicant receives consideration for selection. Thank
you for your time and assistance.
4
dcw/5/17/2011G:\ALHEALTH\HDrive\AHCOMMON\TDN\Admission Letters\EMT\EMT-I\Application From Packet.doc
Recommendation Form Continued:
Applicant’s Name
Last
First
Middle
1. Please rate the applicant in the following areas with reference to potential for success as an EMT-Intermediate
student.
Excellent
(a major
strength)
Good
(a strong
point)
Average
(acceptable)
Below
Average
(needs
improvement)
Unable
to
Assess
Intellectual ability
EMT-Basic skills
Accuracy in completing assignments
Organizational skills and efficiency
Willingness to assume appropriate
responsibility
Oral communication skills
Written communication skills
Use of common sense
Problem solving ability
Ability to cope effectively with daily
stress and strain
Recognition of situations that are
outside his/her area of competence
Ability to accept and respond to
constructive criticism
Motivation in the volunteer/work
situation
Concern for others
Patient rapport
Emotional stability
Adaptability and willingness to learn
Attendance and punctuality
2. Additional Comments:
Summary Recommendation:
____ I recommend this applicant strongly
____ I recommend this applicant
____ I recommend this applicant, but with reservations
____ Not recommended
Evaluator's Signature
Printed Name/Title:
May we contact you if we have further questions?
Date
Telephone No:
5
dcw/5/17/2011G:\ALHEALTH\HDrive\AHCOMMON\TDN\Admission Letters\EMT\EMT-I\Application From Packet.doc
Recommendation Form
Emergency Medical Technician-Intermediate Program
School of Health Professions, Wellness, and Physical Education
Anne Arundel Community College
101 College Parkway
Arnold, MD 21012
For the Classes Beginning fall 2014
Instructions for the Applicant:
Type or print in black ink your name and the name, title, and affiliation of the person familiar with your
professional or academic performance to whom you are forwarding this evaluation form.
Applicant's Name
Last
First
Middle
Address
Telephone number
Evaluator's Name
Title
Last
First
Institution
By signing below, I hereby give permission to the Emergency Medical Technician Program, Anne Arundel
Community College, to contact the above agency or individual if additional information is needed.
In accordance with federal regulations, materials in student files, such as letters of recommendation, are
open to inspection upon request, unless the student has waived the right of access in advance. Please
indicate your wish by completing and signing the statement below.
I (circle one) DO, DO NOT waive my right to review this letter.
Applicant's Signature
Date
***********
Instructions for the Evaluator:
Please complete this form in its entirety and return it to the applicant in a sealed envelope. If
desired, you may return the letter of recommendation directly to: Tammie Neall,
Admissions/Advisement Coordinator, Anne Arundel Community College, 101 College Parkway,
Arnold, MD 21012. You may attach an additional sheet of paper if the space available on this form is
insufficient for your comments.
The deadline for receipt of all application materials is May 3, 2014 for fall admission. Your
cooperation in returning this form before this date will help ensure that the applicant receives
consideration for selection. Thank you for your time and assistance.
6
dcw/5/17/2011G:\ALHEALTH\HDrive\AHCOMMON\TDN\Admission Letters\EMT\EMT-I\Application From Packet.doc
Recommendation Form Continued:
Applicant’s Name
Last
First
Middle
1. Please rate the applicant in the following areas with reference to potential for success as an EMTIntermediate student.
Excellent
(a major
strength)
Good
(a strong
point)
Average
(acceptable)
Below
Average
(needs
improvement)
Unable
to
Assess
Intellectual ability
EMT-Basic skills
Accuracy in completing assignments
Organizational skills and efficiency
Willingness to assume appropriate
responsibility
Oral communication skills
Written communication skills
Use of common sense
Problem solving ability
Ability to cope effectively with daily
stress and strain
Recognition of situations that are
outside his/her area of competence
Ability to accept and respond to
constructive criticism
Motivation in the volunteer/work
situation
Concern for others
Patient rapport
Emotional stability
Adaptability and willingness to learn
Attendance and punctuality
2. Additional Comments:
Summary Recommendation:
____ I recommend this applicant strongly
____ I recommend this applicant
____ I recommend this applicant, but with reservations
____ Not recommended
Evaluator's Signature
Printed Name/Title:
May we contact you if we have further questions?
Date
Telephone No:
7
dcw/5/17/2011G:\ALHEALTH\HDrive\AHCOMMON\TDN\Admission Letters\EMT\EMT-I\Application From Packet.doc
Anne Arundel Community College
Recommendation Form
Emergency Medical Technician-Intermediate Program
School of Health Professions, Wellness, and Physical Education
Anne Arundel Community College
101 College Parkway
Arnold, MD 21012
For the Classes Beginning fall 2014
Instructions for the Applicant:
Type or print in black ink your name and the name, title, and affiliation of the person familiar with your
professional or academic performance to whom you are forwarding this evaluation form.
Applicant's Name
Last
First
Middle
Address
Telephone number
Evaluator's Name
Title
Last
First
Institution
By signing below, I hereby give permission to the Emergency Medical Technician Program, Anne Arundel
Community College, to contact the above agency or individual if additional information is needed.
In accordance with federal regulations, materials in student files, such as letters of recommendation, are
open to inspection upon request, unless the student has waived the right of access in advance. Please
indicate your wish by completing and signing the statement below.
I (circle one) DO, DO NOT waive my right to review this letter.
Applicant's Signature
Date
***********
Instructions for the Evaluator:
Please complete this form in its entirety and return it to the applicant in a sealed envelope. If
desired, you may return the letter of recommendation directly to: Tammie Neall,
Admissions/Advisement Coordinator, Anne Arundel Community College, 101 College Parkway,
Arnold, MD 21012. You may attach an additional sheet of paper if the space available on this form is
insufficient for your comments.
The deadline for receipt of all application materials is May 3, 2014 for fall admission. Your
cooperation in returning this form before this date will help ensure that the applicant receives
consideration for selection. Thank you for your time and assistance.
8
dcw/5/17/2011G:\ALHEALTH\HDrive\AHCOMMON\TDN\Admission Letters\EMT\EMT-I\Application From Packet.doc
Recommendation Form Continued:
Applicant’s Name
Last
First
Middle
1. Please rate the applicant in the following areas with reference to potential for success as an EMTIntermediate student.
Excellent
(a major
strength)
Good
(a strong
point)
Average
(acceptable)
Below
Average
(needs
improvement)
Unable
to
Assess
Intellectual ability
EMT-Basic skills
Accuracy in completing assignments
Organizational skills and efficiency
Willingness to assume appropriate
responsibility
Oral communication skills
Written communication skills
Use of common sense
Problem solving ability
Ability to cope effectively with daily
stress and strain
Recognition of situations that are
outside his/her area of competence
Ability to accept and respond to
constructive criticism
Motivation in the volunteer/work
situation
Concern for others
Patient rapport
Emotional stability
Adaptability and willingness to learn
Attendance and punctuality
2. Additional Comments:
Summary Recommendation:
____ I recommend this applicant strongly
____ I recommend this applicant
____ I recommend this applicant, but with reservations
____ Not recommended
Evaluator's Signature
Printed Name/Title:
May we contact you if we have further questions?
Date
Telephone No:
9
dcw/5/17/2011G:\ALHEALTH\HDrive\AHCOMMON\TDN\Admission Letters\EMT\EMT-I\Application From Packet.doc

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