EMSP Program Application Form

EMSP (EMT & Paramedic)

APPLICATION
Applicants to Hill College EMS Program health courses are responsible for retaining a photocopy of all documentation submitted for their personal records. Once this documentation has been submitted to the Hill College EMS Program, the documentation becomes the sole property of Hill College EMS Program and will not be returned nor photocopied for the applicant, instructors or any other party.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone *

Area CodePhone Number
Mobile Phone

Area CodePhone Number

Program of Interest
I am interested in:*
Required Clinical Requirements
I understand that I must be 18 years old at the time of enrollment in the EMT program.*
I understand that as part of my enrollment in the EMSP program I must meet the mandatory clinical rotation requirements: Immunizations; BLS Provider CPR, Seasonal Influenza, Hep 3 x3, Varicella x2, MMR x2, Negative 2 step TB, FEMA x2, Jurisprudence. Incomplete clinical requirements could prevent me from completing the EMSP program of choice.*
I understand that all EMSP student must register and pay for the SurScan drug test. I understand that I will need to submit a receipt of payment on the first class day. (The link for SurScan can be found on the Hill College EMSP website)*
I understand that all EMSP student must register and pay for the SurScan criminal background check process. I understand that I will need to submit a receipt of payment on the first class day. (The link for SurScan can be found on the Hill College EMSP website)*
I understand that all student will need to meet the EMS Functional Position as outlined by the Functional Position Description ECA EMT AEMT statement located on the Hill College EMSP department website.*

Paramedic applicants only
I understand that I must have a valid Texas EMT-Basic certification to qualify for possible selection in the Paramedic program.*
Additional application requirements: (Health Screening); SurScan Drug testing and Background - student must register and pay for test.Cost and link on the EMSP website. The Hill College EMSP department will inform the students of the date of the drug test.*

HEPATITIS B IMMUNIZATIONS
Healthcare workers have three(3) to five (5) times the risk of the general public of acquiring Hepatitis B. Hepatitis B represents the major occupational infectious disease hazard of health care workers. THE CENTER FOR DISEASE CONTROL (CDC) AND THE OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) RECOMMEND VACCINATION OF ALL HEALTH CARE WORKERS. As a student in a health care field, you will have direct contact with patients who could be Hepatitis Carriers. THEREFORE, IT IS REQUIRED THAT YOU OBTAIN THE SERIES OF THREE (3) IMMUNIZATIONS FOR HEPATITIS B, OR PROVIDE PROOF OF SEROLOGIC CONFIRMATION OF IMMUNITY TO HEPATITIS B VIRUS OR YOU MUST QUALIFY FOR ONE OF THE EXCLUSIONS LISTED IN RULE 97.62. Student, by submitting the HC EMS application acknowledges receipt of this document and understands its contents. . If I do not have the Hepatitis B series and I choose not to obtain the Hepatitis B immunizations and I do not qualify for any of the Exclusions in Rule 97.62, I will not be considered for admission into the program.*

Student Liability Insurance

Disclosure and Agreement
All students are required to carry professional liability insurance. The insurance is provided by the college and the cost is included in fees assessed at registration.*

Major Medical Health Insurance

Disclosure and Agreement
All students need to be aware that many facilities now require the student to carry major medical health insurance. The student will be required to cover the cost incurred for carrying major medical health insurance not Hill College. If the student does not have required major medical health insurance, they will not be allowed to attend clinical. The facilities in which you will be learning does not provide worker compensation or other medical benefits to the student. If the student becomes sick or injured as a result of participating in the Hill College EMS Program the student will be responsible for any and all costs that are associated with the treatment.*

EMS Criminal History

Disclosure and Agreement
For students in a Emergency Medical Services course who may have a criminal background, please be advised that the background could keep you from being licensed by the State of Texas. If you have a question about your background and licensure, please speak with your faculty member or the department chair. You also have the right to request a criminal history evaluation letter from the applicable licensing agency.*

HILL COLLEGE EMS PROGRAM APPLICATION SUBMISSION STUDENT AGREEMENT
I certify that all information and statements in this application and accompanying supplemental materials are true, complete and correct to the best of my knowledge and belief. I understand that any false statements or omissions made by me in connection with my application may be grounds for rejection of my application or dismissal from the EMSP program. I give Hill College EMS Program permission to submit my personal information, this includes criminal background and drug screening results and immunization and TB documentation, to any of the facilities in which I will be doing clinical practicum while I am a student at Hill College EMS Program.*

Check to certify
Applicant's Name*
By typing your name and clicking on the "submit" button, you've electronically signed this form.
Date*

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Date
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EMSP (EMT & Paramedic)