YOU  WILL  BE  PUT  ON  A  WAITING  LIST  until  the  following  documents  are  received:  (1.  DOH  3312  form  –  Verification  of  Membership;  2.  Registration  form  

and  3.  Applicant  Response  Form)  

All  Registrations  must  be  taken  or  mailed  to  our  Wicks  Hall  015.  Students  will  not  be  permitted  to  enter  the  course  on  Angel  

EMT  Student  Registration  Form  –  Fall  2015  Name:  ________________________________________________  Last  4  of  SSN:  XXX-­‐XX-­‐_  _  _  _  DOB:  ____/____/______                                  Last                                                                                          First                                                                                        MI  

Maiden/  Previous  Name  (if  any)  ____________________________  E-­‐mail  Address:  ______________________________  

Phone  (home):  _____________________  (work):  _______________________  (cell):  _____________________________  

Address:  _______________________________  City,  ________________________  State:  ____________  Zip:  _________  

Are  you  a  New  York  State  Resident?  __  Yes  __  No    Have  you  ever  taken  a  course  offered  by  SUNY  Canton?  __  Yes  __  No  

If  yes,  year  &  semester  attended:  ________________  Are  you  enrolled  in  a  SUNY  Canton  degree  program?  __  Yes  __  No  

Have  you  ever  attended  another  college?  __  Yes  __  No      If  yes,  What  College?  ___________________________________  

High  school  attended:  ______________________________________  Are  you  NOW  a  high  school  student?  __  Yes  __  No  

Year  of  high  school  graduation  or  GED  Awarded:  ________________  

 __  Married  __  Single  __Veteran  __  Male  __  Female  

Have  you  ever  been  convicted  of  a  felony?  __  Yes  __  No  

Have  you  ever  been  dismissed  from  a  college  for  disciplinary  reasons?  __  Yes  __  No  

Ethnic  Code  (Please  Circle)  

(Ethnic  code  information  is  optional)  

Asian  /  Pacific  Islander          American  Indian  /  Alaskan     Black  Non  –  Hispanic   Hispanic                

White  /  Non  –  Hispanic            Non  –  Resident  Alien   Other:  ________________  

 Rescue  Squad  /  Fire  Dept.  ______________________________________________  Phone:  (_____)________-­‐-­‐________  

Please  indicate  the  course  you  are  applying  for  by  checking  the  appropriate  box:  

COURSE   COURSE  NUMBER   COURSE  COST  Basic  EMT  Original  –  SUNY  Canton   Not  Available  At  This  Time   $775  (non-­‐agency  applicant)  Basic  EMT  Refresher  –  SUNY  Canton   Not  Available  At  This  Time   $425  (non-­‐agency  applicant)  Critical  Care  Original  –  SUNY  Canton   Not  Available  At  This  Time   $1,300  (non-­‐agency  applicant)  

       

    Deadline  for  all  registrations  is  August  17th  2015  

 

Mail  to:  SUNY  Canton  EMT  Program,  34  Cornell  Drive,  Wicks  Hall  015,  Canton,  NY  13617  OR  

Fax  to:  (315)  386-­‐7961  If  you  have  any  questions  please  contact  us  at  (315)  386-­‐7973  

***ALL  REGISTARTIONS  MUST  BE  POSTMARKED  FOR  FAXED  BY  THE  ABOVE  DATE  TO  BE  CONSIDERED.***  

 

1    

   

EMT Program Applicant Check List- Fall 2015 Semester

EMT Basic Original and Refresher Classes

o 1. SUNY Canton Registration Form – Fall 2015 o 2. Verification of Membership in an EMS Agency (DOH-3312) o (Note: This must be signed by the member AND the agency representative.) o Applicants who are not affiliated with a New York State agency such as a fire department

Ambulance service, registered first responder department, or an independent rescue squad will be required to pay a tuition cost of $775 as there is no state reimbursement of funding for non-affiliated members. This payment is to be paid in full by October 1 2015.

o 3. Basic Refresher students only: Basic refresher students MUST include a copy of his or her EMT card. The state requires this to show proof of taking a basic original class.

Advanced EMT and Critical Care Original Classes

o 1. In addition to items 1 and 2, any student registering for the AEMT or Critical Care MUST include a copy of his/her current EMT card. This card cannot expire before the scheduled state written examination date.

o 2. CC Refresher students only: Critical Care refresher students MUST include a copy of

his or her Critical Care Card. The state requires this to show proof of taking an original Critical Care class.

 

2    

Medical Information for Original Students

o 1. Although medical information is not needed when riding in an ambulance, in the past

students have waited until the last couple of weeks then find they cannot get the ride time completed. Now they need to do Emergency Room clinicals and their medical records are incomplete. Therefore, we request that copies of all the information outlined on the Health and Physical Requirements be included with the registration application. If not available, please obtain and submit this information as soon as possible. A health physical and two (2) PPD/TB test results must be current within the past year. This information is required by the hospitals in order to do clinical hours at their facility. Also, the hospitals have updated their medical requirements to include dates of proof of Varicella (chicken pox) vaccination or a positive titer for antibodies and the date of the applicant’s last tetanus shot.

All Applicants

o 1. All registrants must sign below and include this form with registration materials.

o 2. I hereby grant permission to SUNY Canton to withdraw me from the course for failure to

attend classes OR for not being able to complete the course as scheduled.

_________________________/___________________________________/____________________ Print Name Signature Date

(Please submit both copies)

Mail this signed Applicant Response Form, (along with ALL required documentation) to:

SUNY Canton · 34 Cornell Drive, EMT Program – Wicks hall 027, Canton, NY 13617

or fax to (315) 379-3979

SUNY  Canton  EMT  Program  Fall  2015  

EMS  Course  Information  Full  course  information  can  be  found  at  www.canton.edu/emt  

*For  Refresher  courses,  an  expired  card  is  also  acceptable  if  you  have  let  your  card  run  out.  Otherwise,  please  submit  a  copy  of  your  current  card  with  your  registration  materials.    **All  students  taking  an  original  Advanced  or  Critical  Care  course  must  possess  a  current  New  York  State  EMT  certification  that  will  be  valid  throughout  the  entire  Advanced  or  CC  course.  A  copy  of  the  EMT  card  is  to  be  submitted  along  with  your  registration  materials.  If  you  card  is  going  to  expire  prior  to  the  State  Exams  for  that  course  you  must  take  a  refresher  course  first.  

 

 

 

 

 

Course  Name   Instructor   Location   Dates   Days   Times  EMT  Original   Chris  Miller,  CIC   Wicks  Hall  102   8/24/15  –  

12/17/15  Monday,  Wednesday,    

Some  Saturdays  6:30pm  -­‐  9:30pm  (Mon,Wed)  

9am-­‐noon,  1-­‐4  pm  (Sat)  

EMT  Refresher   Storm  Cilley,  CIC   Wicks  Hall  204   9/8/15-­‐  11/19/15  

Tuesdays  &  Thursdays   6:30pm  –  9:30pm  

Advanced  EMT  Original  

June  Wood,  CIC   Dana  Hall  207   8/25/15-­‐  1/17/15  

Tuesdays  &  Thursdays   6:30pm  –  9:30pm  

Critical  Care  Original   June  Wood,  CIC   Dana  Hall  207   8/25/15-­‐  6/16/16  

Tuesdays  &  Thursdays   6:30pm  –  9:30pm  

Course  Name   Copy  of  EMT  Card   Hours  of  Mandatory  ER  /  Hospital  Time  

Hours  of  Mandatory  

Ambulance  Time  

NYS  EMT  Practical  Exam  Date  

NYS  EMS  Final  Written  Exam  Date  

Basic  EMT  Original  

N/A      

    Wed.  Dec.  9  2015  Sat.  Dec.  12  2015  ½  of  the  class  each  night  

 Thur.  Dec.  17    2015  

Basic  EMT  Refresher*  

X   None  Required   None  Required   Tues.  Dec.  8  2015   Thur.  Dec.  17    2015  

Advanced  EMT  Original  

X       Thur.  March  10  2016  

Thur.  March  17  2016  

Critical  Care  Original**  

X        

     Sat.  June  10  2016  

 Thur.  June  16  2015  

Combined  10  hours  (If  all  ride  time,  minimum  of  6  calls)  

The  hours  for  these  2  classes  may  include  hours  in  the  ER,  OR,  ICU,  Maternity,  

Respiratory  and  Ambulance.  As  well  as  specific  patient  categories.    

Breakdown  will  be  given  out  on  your  first  night  of  class  

HEALTH AND MEDICAL LIABILITY REQUIREMENTS

*Required for all applicants taking Basic EMT Original OR

Critical Care EMT Original*

A copy of the following medical records and the department’s medical liability insurance or personal medical liability insurance proof should be submitted along with the registration material.

*Requirements for All Original Students* þ ACCEPTABLE PROOF Doctor, clinic, military, school, employment, or fire department/rescue squad physical and/or immunization records.

o

MEDICAL LIABILITY INSURANCE A current copy of your Department’s liability insurance or a copy of your personal liability insurance.

o

PHYSICAL Copy of a physical exam completed within the last year. A health reassessment form can be completed if a physical was done 1-3 years ago.

o

PPD Mantoux (TB) Dates and signatures of 2 negative results within last 12 months or a negative chest x-ray within 5 years for anyone with a history of a positive PPD test result.

o

RUBEOLA (Red Measles) Proof of one of the following is attached: 1. Dates of 2 live Rubeola immunizations; both given after 1957 and on or after

the 1st birthday. These would be MMR vaccinations. 2. Dated and signed results of a positive titer or a copy of the lab results. Note: Exempt if born before January 1, 1957.

o

RUBELLA (German Measles) Proof of one of the following is attached: 1. Date of 1 live Rubella immunization given on or after the first birthday. These

would be MMR vaccinations. 2. Dated and signed results of a positive titer or a copy of the lab results.

o

MUMPS (optional) Proof of one of the following is attached: 1. Date of 1 live mumps immunization given on or after the first birthday. 2. Dated and signed results of a positive titer or a copy of the lab results. 3. MMR is the same as the above three individual immunizations

o

HEPATITIS B One of the following must be documented:

oDates of the completed series of all 3 immunizations. oDate of first immunization showing series is in progress. oDated and signed results of a positive titer or a copy of the lab results. oSigned waiver refusing the immunizations.

o

VARICELLA (Chickenpox) The hospitals are requiring dates of two chickenpox vaccinations or proof of a positive titer for antibodies. A note from your doctor stating you have had them is no longer acceptable.

o

Tetanus Shot: Tetanus is good for 10 years. It is suggested that if someone’s has not had a vaccination in the last 2-3 years that they receive the booster of Tdap due to pertussis outbreak that has occurred in the last few years

o

FLU VACCINATION The hospitals require a flu vaccine for ALL students.

o _______________________ / _________/________ _______ _ Applicant’s Signature Date Print Name

It is the sole responsibility of each student to meet health and medical liability requirements.  

If needed, this form is for your use SUNY Canton Health History, Physical Exam Immunization Form

SUNY Canton, EMT Program – FAX: (315) 379-3979

Print Name: Social Security #: û û û - û û - ___ ___ ___ ___Date of Birth________________ Address_______________________________________City_______________________________State__________________Zip Code___________ Telephone Number: Home ( ) Cell Phone: ( ) PART I: IMMUNIZATION/MENINGITIS REQUIREMENTS:

IMMUNIZATIONS Required by Public Health Law 2165: Measles Mumps and Rubella: MUST BE GIVEN AFTER Jan. 1, 1969 and ON OR AFTER THE first BIRTHDAY. Doses must be at least 28 days apart. MMR: 1st____/____/____ 2nd____/____/____ Mo Day Yr Mo Day Yr OR Measles (Rubeola) 2 doses: 1st____/____/____ 2nd____/____/____ Mo Day Yr Mo Day Yr Rubella____/____/____ Mumps____/____/____ Mo Day Yr Mo Day Yr A titer proving immunity for each of the above is an acceptable alternative to receiving the immunizations. A copy of the results is required. Please attach to this form. 2. Two Varicella Vaccinations or proof of titer: 1st ____/____/___ 2nd____/____/____ titer ___/____/___

# 1 Tb Mantoux: Required for all original EMT students. A second PPD Mantoux is required unless the two tests are for two consecutive years. (2012 & 2013) Date: _________________ Result in mm ____________________ Signature of person reading results_______________________ If positive Chest x-ray Date:_______ _________ Result:_______ _ _ #2 Tb Mantoux: (2nd PPD must be at least one week after the first PPD ) Date: __________________ Result in mm __________________ Signature of person reading results_______________________ If positive Chest x-ray Date:_______ _________ Result:_______ _ _ HEPATITIS B VACCINE: If completed list dates of each dose: Dose #1____________ Dose #2____________ Dose #3____________ Date of last Flu shot________________ Date of last Tetanus Shot: _____________________________

PART II: PHYSICAL EXAM: (name)

AGE: SEX: B/P WEIGHT: HEIGHT __________ VISION FAR: R: 20/__________________ L: 20/ __________________ □ without correction □ with correction

PHYSICAL EXAM

NORMAL ABNORMAL COMMENTS

1. GENERAL APPEARANCE

2. SKIN

3. HEENT

4. NECK

5. LUNGS

6. HEART

7. ABDOMEN

8. MUSCULOSKELATAL

9. PSYCHIATRIC

To the best of my knowledge this student (is/is not) free from physical or mental impairments including habituation or addition to depressants, stimulants, narcotics, alcohol or other behavior altering substances which might interfere with the performance of his/her duties or would impose a potential risk to patients or personnel.

Examining Health Care Provider (MD, DO, NP, PA) (Signed)

Print Name Phone: _________________________ Date ________________

RETURN FORM TO: SUNY Canton, EMT Program, Wicks hall 027, 34 Cornell Drive, Canton NY 13617

TEXTBOOK INFORMATION    EMT  basic  course  Pre-­‐Hospital  Emergency  Care  by  Brady,  12th  Edition    Advanced  EMT  and  Critical  Care  Course  Intermediate  Emergency  Care  principles  &  practice  by  Brady      Books  may  be  ordered  on  line  at  www.bradybooks.com.    

or    Another  avenue  that  may  be  considered  is  going  to  Amazon.com  and  search  for  EMT  books.    All  the  options  for  purchase  will  be  listed  there.