ODEMSA EMT Course Application

ODEMSA EMT Course Application: Held at Prince Edward Vol. RS

Please read the Course Information Packet in its entirety before filling out this application.
Name *

First Name Last Name
Email *
example@example.com

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
Date of Birth *

- Month - Day Year
Students MUST be 16 before October 4, 2018
Date Submitted *

- Month - Day Year
Date
Are you a member with an EMS agency? If so, please type your agency below, if not please put 'not affiliated'. *
Please choose your CPR certification from the options below: *

American Heart Association - Basic Cardiac LifeSupport - "Healthcare Provider" American Red Cross - "CPR/AED for the Professional Rescuer and Healthcare Provider" or CPR/AED for Lifeguards Emergency Care and Safety Institute "Professional Rescuer" / "Healthcare Provider CPR & AED" EMS Safety Services, Inc. – CPR/AED for Professional Rescuers (2/1/2014) American Safety and Health Institute –"CPR-PRO Medic First Aid - BLS for Professionals "BLS PRO" National Safety Council – "Healthcare and Professional Rescuer" ProCPR – "Healthcare Provider" I do not have CPR yet
I understand that the didactic information is ALL online. I will be responsible for completing ALL lectures, tests, quizzes, assignments, and tests by their scheduled due date. *

Yes
I understand that I will need a computer with access to high speed internet to complete the course. *

Yes
I understand that this course is physically demanding including kneeling, performing CPR, crouching, bending, and lifting upwards of 150 lbs. I also understand that there is a flight of stairs at the station I will be responsible for navigating to get to the classroom. *

Yes
I understand that I have to complete an APPROVED CPR class before the first day of the course and either have an Agency Affiliation form or the correct amount of Liability insurance. *

Yes
I understand I will be provided a uniform and it will be mandatory to wear it. I understand I will be asked to leave if I am not in approved attire. *

Yes
I understand that I must complete all course and lab work by end of course date. *

Yes
I understand that it is my responsibility to set up clinicals at an approved location to get my patient contacts. I can expect reasonable help from my instructors and Course Coordinator. *

Yes
I understand ODEMSA charges a fee for this course which is due by end of date on orientation night and I have read the refund policy. *

Yes
I understand that if the Course Coordinator feels I am not progressing (i.e. completing online coursework, being a disruption in class) I will be removed from the course in accordance with the refund policy. *

Yes
Why do you want to take this course? *
Small explanation or reason
Should be Empty:

ODEMSA EMT Course Application: Held at Prince Edward Vol. RS