Paramedic Application - Academic Year 2024

Endeavor Health Highland Park Hospital EMS System

EMS Education Program Paramedic Application - Academic Year 2024
Applicant Information
Name*

First NameLast Name
Personal Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Personal Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security Number*
Current Employer*
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Occupation
Length of Employement
Current Hours (Per Week)
Employers Phone Number
Please enter a valid phone number.
Applicant Background Information
Have you ever applied for a Paramedic Training Course at this level before?*

YesNo
If yes, site(s) and date(s)
Reason for not attending course(s)
Have you ever attended a Paramedic Training Course of this level before?*

YesNo
If yes, site and date
Reason for not completing course:
Have you ever been convicted of a felony?*

YesNo
If yes, what felony and date:
Applicant Attestation
I First Name Last Name attest to completing this application in its entirety. I hereby certify that all statements made on or in connection with this application are true to the best of my knowledge and belief. I understand and agree that any false statement or omission of fact may disqualify me from acceptance into the NorthShore University Health System, Highland Park Hospital EMS Education Program. I further understand that any false information may result in my removal from the program. I authorize the program to verify the statements made on or in connection with this application.
Signature*

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Date*

MonthDayYear
Date

Applicant Personal Statement

Please compose a personal statement on your motivation for attending this program. For example, how have you prepared yourself? What do you hope to accomplish? What are your future career goals?
Statement:*

Declaration of Independent Status

If you are not currently employed as an EMT in Region 10 and are requesting Independent Status as a student in this course or you are currently employed as an EMT but are not being sponsored by your employer, please sign below:
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date

Declaration of Sponsorship / Declaration of Financial Support

If you are currently employed as an EMT in Region 10 and your employer is sponsoring your participation as a student in this course, please complete this form. Note: If your employment status changes at any time during the application process or at any time during the course, you must notify the EMS Office within 10 days. Your acceptance into the program is contingent upon your declaration of sponsorship.
Name

First NameLast Name
Employer Agreement EMT Employment Information
Current Employment Status:

Full TimePaid On-CallVolunteer
Type of Provider:

PrivateMunicipalVolunteer
Program Expenses:

Applicant is Self-PayApplicant is Employer Supported
Name of Administrative Representative of Sponsoring Department

First NameLast Name
Name of Sponsoring Department/Agency
Sponsoring Department/Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature of Authorizing Employer

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Title of Authorizing Employer
Sponsoring Department/Agency Phone Number
Please enter a valid phone number.
Sponsoring Department/Agency Email
example@example.com
Date

MonthDayYear
Date

Region 10 - Out of System Agreement

This must be completed when an applicant is requesting to attend this training program outside their primary EMS System Affiliation
Applicant Name

First NameLast Name
Primary EMS System Affiliation
Please state reason for not attending primary system Paramedic Course:
To Be Completed By Region 10 EMS System Coordinator

This must be completed when an applicant is requesting to attend this training program outside of their primary EMS System affiliation.
I hereby affirm that First Name Last Name , is a member of the Region and is a provider is the Department/Agency Name EMS System
I am aware that he or she is applying for acceptance into NorthShore University HealthSystem - Highland Park Hospital EMS System Paramedic Training Program. I approve of this application and agree to permit this student to obtain his or her field internship requirements in this EMS System, pending Medical Director(s) approval.
Signature of EMS System Coordinator/Administrative Director

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Date

MonthDayYear
Date
Signature of Applicant

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Date

MonthDayYear
Date

Authorization for Release of Academic Information
I First Name Last Name authorize the release of appropriate academic information to the following agencies; EMS employer (if applicable), host provider agency, College of Lake County, hospitals with specialty clinical areas,
the Illinois Department of Public Health, and the Highland Park Hospital EMS System. In addition, I authorize the College of Lake County to release appropriate academic information to NorthShore University HealthSystem Highland Park
Hospital EMS System.
Signature*

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Date*

MonthDayYear
Date

Guidelines for Student Recommendation Form

All applicants must secure one professional letter of recommendation and one educational letter of recommendation, to be considered for admittance to the Paramedic program.
1. All applicants must secure one professional letter of recommendation and one
  educational letter of recommendation to be considered for admittance to the
  Paramedic program.
2. The recommendation must be from an educational reference such as a previous or current teacher, professor, or EMT instructor AND a recommendation may be from a professional reference; such as a supervisor, employer, or colleague.
3. Recommendations from family members are not permitted.
4. A recommendation form should be given to the reference, along with an envelope. However, before you give your reference a form YOU MUST COMPLETE THE TOP SECTION OF THE FORM outlining your intention to review the information.
5. Instruct the Evaluator to return the completed recommendation form to you in a sealed envelope with their signature across the seal.
6. The letter of recommendation may be submitted separately from your application; during the interview process. However, your application will not be complete without it.
7. It is to your advantage to submit the letter of recommendation with all other
  application materials.

Confidential Recommendation for Endeavor Health – Highland Park Hospital Paramedic Program

APPLICANT: Please complete this area ONLY.
Applicant Name

First NameLast Name
“The Family Educational Rights and Privacy Act of 1974 and its amendments guarantee student access to educational records concerning them. Students are also permitted to waive their rights to access recommendations.”

The following signed statement indicates the applicant’s wish regarding this recommendation:

I waive I Waive I Do Not Waive* my right to see this form or any supplementary notes or letters pertaining to this reference form.
Signature*

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Date*

MonthDayYear
Date

Endeavor Health - Highland Park Hospital EMS System

Paramedic Application Checklist – Academic Year 2024
Applicant Name*
Check off the items below and enclose the items with your application. All items must be completed and included for your application to be considered Incomplete applications will be denied.
Email Address*
example@example.com
$100 non-refundable application fee *
Copy of current Healthcare Provider CPR card (both sides)*
File Upload*

Cancelof
Copy of current driver's license or state photo identification card*
File Upload*

Cancelof
Copy of current Illinois EMT or AEMT license (wall license)*
File Upload*

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Unofficial high school or college transcript(s) or proof of GED completion *
File Upload*

Cancelof
Completed Academic Proficiency Requirements verified by documentation provided and included (page 7)*
File Upload*

Cancelof
Verification of current continuing education hours. Example: Letter of Good Standing from current EMS system or training records.*
File Upload

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Record of Covid Vaccination *
If you are not vaccinated please reach out to the EMS Department at 847 480 3981 for an exemption form. Exemption form will be required to be completed and submitted prior to beginning of the program.
File Upload

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Should be Empty:

Endeavor Health Highland Park Hospital EMS System

Applicant Information

Applicant Background Information

Applicant Attestation

Education

High School

Undergraduate Education

Graduate Education

Pre-requisite: BIO 111 Human Form and Function or Anatomy/Physiology or Equivalent

EMT Certification

Accommodation

Applicant Personal Statement

Declaration of Independent Status

Declaration of Sponsorship / Declaration of Financial Support

Employer Agreement EMT Employment Information

Region 10 - Out of System Agreement

To Be Completed By Region 10 EMS System Coordinator

Academic Proficiency Requirements

Reading and Writing Readiness:

Basic Algebra Readiness:

Authorization for Release of Academic Information

Guidelines for Student Recommendation Form

Confidential Recommendation for Endeavor Health – Highland Park Hospital Paramedic Program

Endeavor Health - Highland Park Hospital EMS System