Please print off the form below, fill out and attach all supporting documents. Once you have a completed application and all documentation please send or drop off your application to:
Kirk Mittelman
University of Utah
Center For Emergency Programs
1901 East South Campus Drive
Annex C, 2066
SLC, UT 84112
Name:
Street Address: City: State: Zip:
Home Phone: Cell Phone: Other Phone:
Date of Birth:
Utah Drivers License Number: Expiration Date:
Utah EMT Number: Year Certifited: Expiration Date:
Agency Affiliation? Yes No Where:
When affiliated? May we contact them? Yes No
Agency Contact Person: Phone:
Other Agency Affiliation: May we contact them? Yes No
Agency Contact Person: Phone:
Where did you attend high school? Year Graduated or Equivalent:
Are you available to attend this program from January 2007 thru December 2007? Yes No
Do you understand the proposed schedule of the program? Yes No
Do you have reliable transportation available that will allow you to travel over 70 miles from the University main campus for clinical experiences? Yes No
Do you have any medical problems that may preclude you from completing the course? Yes No
Do you understand the total course fee is due in full by December 15th, 2008 and is non-refundable? Yes No
By signing this application form you are allowing Mt Nebo Training and the University of Utah to evaluate your worthiness to enter and likelihood of completion of the Paramedic Course.
The applicant is aware that all application fees of $150 are non-refundable or transferable and will be applied to course tuition if selected to participate in the Paramedic Course.
Applications that are not accepted for the current program will receive a partial refund of the application fee of $100. There is no promise that simply by applying for the course students will be accepted to participate. Based on the nature of the course all requirements may be met and a student may not be accepted based on the entrance committee’s estimation that the student will not succeed. This does not mean that the student is may not reapply after more preparation is completed.
The applicant must attach to this completed application the following documents:
- Copy of current Utah and all other EMT Certifications
- Copy of current BLS/Health Care provider CPR card
- A typed resume
- Three letters of reference attesting to the applicant’s character, academic abilities and overall experience in EMS.
- A letter of intent and interest to participate in the program.
- Description of patient care experience in the medical field, this may be as a volunteer or professional medical provider and/or Utah EMT Intermediate certification.
- Proof of completion of the following pre-requisites (complete transcripts are preferred and all must show at least a passing grade of “C” or better)
- A minimum of Introduction to Anatomy and Physiology (BIOL 2320)
- A minimum of Introduction to College Writing (Writing 2010)
- A minimum of College Algebra (MATH 1010)
- A minimum of Introduction to Medical Terminology (HEDU 3030)
- One wallet size photo
The applicant understands that in addition to the items listed they will also be required to complete the following:
a. Pre-course testing achieving a minimum score
i. This test will be comprised of Basic and some Intermediate level EMT questions, medical terminology and medical related math questions
b. Pre Course physical fitness testing
i. This testing will be comprised of a job related tasks to be completed in an appropriate amount of time as described by the job duties of a Utah EMT Paramedic.
c. Immunizations (adult boosters and Hepatitis A and B series under way) must be completed prior to first day of class
d. TB testing after December 1st, 2008
e. Successful completion of the entrance interview
The course fees are currently as follows:
· Course Fees (payable to Mt Nebo Training): $5800
· University of Utah Tuition Per Semester Desired: $550 for 15 credits/ All Semesters $1650 for 45 total credits.
I , , have read and understand the entrance requirements for the Paramedic Course. I am aware of the refund policy of the course and agree to that provision. I also will allow Mt Nebo Training and the University of Utah to complete a background check to prove my character and worthiness to enter the Paramedic Course.
I am also aware of the unique physical and mental strains the Paramedic Course will place on me and my family. I am willing to commit the amount of time required to make my experience a successful one. I recognize the length of the course is approximately one year (3 semesters following the U of U semesters) with unique scheduling and class times.
If accepted to the program I understand that if I decide to leave the program for any reason that my tuition and course fees will be forfeited. I also agree to abide by the course rules and regulations as set forth by the University of Utah, Mt Nebo Training, the National Registry of EMT’s and the Utah Bureau of Emergency Medical Services.
Signature: Date:
