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Application for Admission - Critical Care Paramedic Program

Please note: Not all qualified applicants can be admitted to the Critical Care Program due to the limited number of spaces available.

PERSONAL INFORMATION

Full Name:
Gender:
Male     Female
Street Address:
City:
State:
Zip:
Home Phone:
Alternate Phone:
Email:
Date of Birth:

Admission Requirements:

  • Current EMT-P certificate (State of Tennessee or National Registry of EMT [NREMT]) – this license must be maintained throughout the program.

    Applicants MUST have been licensed as a paramedic for a minimum of two years prior to January 1, 2013.

    Date of initial Paramedic Certification
  • ACLS (Please upload if you have a digital copy available)
  • Current Cardio-Pulmonary Resuscitation (CPR) certification, Healthcare Provider or Professional Rescuer (Please upload if you have a digital copy available)
  • Trauma Course (BTLS, PHTLS, or ITLS) (Please upload if you have a digital copy available)
  • PALS (Please upload if you have a digital copy available)

The following documents must be received prior to the start of the program (If NOT an STHS employee):

  • Proof of Hepatitis-B vaccine or immunity
  • Proof of MMR
  • Proof of TB test within the last year
  • Proof of Health Insurance
  • Proof of Professional liability insurance from your current employer

Please list and describe below any relevant EMS employment and/or volunteer work or any relative experience you would like to be considered.

Dates Employer/Activity Position/Duties

Current Employer:
Date hired:
Position:

List previous employer or other EMS Experience – please list in detail

EMERGENCY CONTACT INFORMATION

Name:
Relationship:
Address:
Phone:

Applicant's Statement

I, the undersigned, apply for admission to the Paramedic Certificate Program at Saint Thomas Health. I agree that the information given on this application is true to the best of my knowledge. I realize that failure to disclose fully and accurately all facts relating to this application could be grounds for dismissal. I understand that, once accepted, it is my responsibility to familiarize myself with, and abide by, the policies, rules, and regulations of the program. Further, I hereby grant permission for me and/or my schoolwork products to be photographed or videotaped and used by Saint Thomas Health. This application is made with my consent and I hereby guarantee the payment of all financial obligations incurred.

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