EMT STUDENT INFORMATION

STUDENT INFORMATION FORM

ARES Med Solutions/EMS Training NY
Date*

MonthDayYear
Date
Student Name*
ARES Program*
ARES Program Option *
Please pick your course program
ARES Representative/Instructor
Cell Phone*
Email Address*

Confirmation Emailexample@example.com
Home Phone
Address*
City*
State*
ZIP Code*
Date of Birth*

MonthDayYear
DOB MM/DD/YYYY
Gender (How do you identify? Pronouns?)
Payment Plan Option*
(In-house financing. third-party financing. employer paying, pay in full)
ARES Alumni (If yes, what class?)
Veteran (If yes, what branch & rank?)
Emergency Contact Name*
Enter full name
Emergency Contact Phone Number*
Preferred Ambulance Company
Employer Program

Payment Information

PAYMENT CONTRACT
Student Name*
By signing this Agreement i acknowledge and reaffirm my outstanding debt pertaining to fees/fine of   1750.00*   with Advanced Rescue Education Solutions/EMS Training LLC as of   Date*   .

I agree and accept responsibility for a deposit due upon enrollment of   *   and   *   monthly payments of
  * Payments are due 30 days from initial deposit and will continue monthly until the account is paid in full.

I understand all payments are to be maybe payable to EMS Training LLC and mailed to EMS Training LLC, 2825 Third Ave, Ste 301, Bronx, NY 10455.

I understand it is my responsibility to notify student affairs of any changes to my address, phone, or email changes.

I understand any payment returned as insufficient funds, stop payment, account close, or any other reason will cause the account to become delinquent and thereafter placed in a collection status which may include referral to collection agency.

I understand that I may make additional payments beyond the agreed monthly payment at any time; however, I am still responsible for making minimum monthly payment.

I understand i will not able to register for additional classes or receive a completion certificate until the debt is paid in full.
I have carefully and completely read this agreement and fully understand the purpose, intent and effect of this agreement. I have voluntraily executed the agreement by action of my own free will.
Print Name*
John Doe
Sign Name*

Clear
Date*

MonthDayYear
Date

Recurring Payment Authorization Form

Here’s How Recurring Payments Work: You authorize regularly scheduled charges to your checking/savings account and/or credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge willappear on your bank statement. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 3 days prior to the payment being collected.
I Name* authorize Advanced Rescue Solutions LLC/EMS Training LLC. To charge my card/bank account indicated below for the tuition deposit of $500.00*on Date and 5 Payments of $ 250.00* to be pulled each month on the 1st* for payment of my tuition in the amount of $ 1750.00* .
Billing Address

Street Address

CityState

Zip Code
Phone
Email
example@example.com
Signature

Clear
DATE

MonthDayYear
Date
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Advanced Rescue Education Solutions/EMS Training LLC in writing of any changes in my account information or termination of this authorization at least 15 daysprior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that becausethese are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Advanced Rescue Education Solutions/EMS Training LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorizedrecurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduledtransactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form

AMERICAN DISABILITIES ACT (ADA) FEDERAL REGULATIONS (REVISED)

In accordance with ADA Federal Regulations, the sponsoring department/organization may request a verbal examination process for their personnel who have a qualifying disability covered by the ADA regulations. To request verbal testing as a reasonable accommodation, the department and/or student must submit a written request with supporting documentation from a professional with an appropriate medical licensure to make a diagnosis and to recommend the reasonable accommodation. This must be requested each time a student registers for attendance as we do not keep the information on file for reference. While all reasonable accommodations will be made, this is a limited access course due to the nature of the job being trained for.
Use the section below to upload a picture of your state ID card or Drivers license, you may also upload any addiitonal documents imunizations records, BLS Provider CPR Cards. This section is required.

Picture for Student ID refer to requirements below
Student ID Photo (required) You can take a photo or use the upload feasture to upload you photo. photo must meet the guidelines below, they are the same req. for Passport Photos.

ID Photo requirements
- In color
- Sized such that the head is between 1 inch and 1 3/8 inches (22 mm and 35 mm) or 50% and 69% of the image's total height from the bottom of the chin to the top of the head. View the Photo Composition Template for more size requirement details.
- Taken within the last 6 months to reflect your current appearance
- Taken in front of a plain white or off-white background
- Taken in full-face view directly facing the camera
- With a neutral facial expression and both eyes open
- Taken in clothing that you normally wear on a daily basis
  Uniforms should not be worn in your photo, except religious clothing that is worn daily.
- Do not wear a hat or head covering that obscures the hair or hairline, unless worn daily for a religious purpose. Your full face must be visible, and the head covering must not cast any shadows on your face.
  Headphones, wireless hands-free devices, or similar items are not acceptable in your photo.
Photo examples Click Here
Take Photo

Student Agreement and Academic Policies
By signing this form, you agree that you have received, read, and acknowledge the contents of the syllabus and the rules governing the course and program. As no document can account for all possible concerns or situations, any issue not explained in this document will be resolved with input from the instructor, course coordinator, and program director as needed to obtain the best outcome for all parties and maintain the integrity of the EMS program.
Name*

First NameLast Name
Signature*

Clear
Date

MonthDayYear
Date

Course Entry Requirements & Course Guidelines

For completion of the ARES EMT program, the student will be required to pass a basic background check with fingerprints included. Students will have to show proof of applicable immunizations and complete a HIPAA and bloodborne pathogens training with documentation scanned and emailed to the lead instructor’s email address.

Valid criminal background check to include:

Social security number verification
Criminal search (7years or up to 5 criminal searches)
General Services Administration (GSA) list of parties excluded from federal programs
Office of Inspector General (OIG) list of excluded Individual/Entities
US Treasury, Office of Foreign Assets Control (OFAC), list of Specially Designated Nationals (SDN)
Violent Sexual Offender and Predator Registry Search
Immunizations documentation should include:

Proof of MMR;
Hepatitis B vaccination or appropriate waiver.
Negative TB/PPD skin test or Negative Chest X-ray.
Proof of Varicella vaccine; if no history of chickenpox, or appropriate waiver.
Proof of Tetanus vaccine or appropriate waiver.
Proof of Influenza vaccine or appropriate waiver (flu season);
Evidence of training and education in occupational exposure to blood borne pathogens, protective practices to avoid contamination, and procedures for decontamination in case of exposure to infectious materials.
COVID vaccines may be required by the ambulances students will ride with. If a student is unvaccinated, they may not be able to ride with select ambulance providers.

Course Completion Requirements:

Successful completion of this course requires adherence to course policies, achieving a course average of 70% with a minimum score of 70% on each module exam, a minimum score of 70% on the course final examination, and successfully demonstrating all required skills. Should a student fail an exam, they will be allowed to research and write a one-page overview of the module with an emphasis on the information regarding missed questions in order to receive an unlock code from the instructor to retest. Technical difficulties and extenuating circumstances causing failing grades will not be subject to this. Students will be allowed one exam retake per module.

Course Attendance Policy:

Student attendance is required at all scheduled bootcamp classes. Students may be dropped from the course for excessive unexcused absences. If a student misses an lecture for an excused reason, they will have 3 days to watch the recording and document their attendance on the appropriate form in order to receive attendance credit.

Excused absences may be granted by the course instructor for extenuating circumstances following a written request in advance of the absence. If three or more unexcused absences occur for any reason, the status of the student will be reviewed by the faculty to determine a disposition. Course failure is likely under these circumstances.

If a student misses any class, he or she is responsible for any missed quizzes, examinations, and material covered in that class session. Prompt arrival is expected at all class activities. It is the student’s responsibility to sign in on the attendance form.

Communication:

Proper lines of communication shall be used for any official topics relating to the EMT course. Such options will include instructor email, ARES Connect Discord server or email instructors and preceptors within the Platinum Education App. Social media such as Facebook, are not to be used for official questions or concerns.

Dress and Appearance:

Student uniform will consist of a black ARES student shirt or black polo shirt, duty belt, black BDU style pants, and black steel or composite toe boots. Students will be expected to wear their student uniform for each day of skills camp as well as during all clinical and field training. Students are reminded that they are representatives of the ARES EMT Program whenever and wherever they are involved with course-related activities. Professional conduct is essential to a successful course experience and EMS career.

Academic Dishonesty:

Academic dishonesty in any form will not be tolerated and is grounds for immediate dismissal from the program and other administrative action. Examples include, but are not limited to:
- Cheating in any form
- Falsification or forgery of academic documents
- Being Dishonest or manipulative
I agree to the follow the guidelines and polices of the course and program as oulined above.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Review the form before submission
Address Map Locator
Should be Empty:

STUDENT INFORMATION FORM

Payment Information

PAYMENT CONTRACT

Student Agreement and Academic Policies