Paramedic Online Application

Full Name (First, Middle, Last)*

Mailing Address*

City*

State*

Zip Code*

Tech T#

Date of Birth*

Home Phone

Cell Phone

Email

Are you currently a licensed EMT/AEMT in Arkansas?*

Yes

No

Please indicate if you are currently a student of:*

Arkansas Tech University

Arkansas Tech University-Ozark Campus

Not Applicable

Have you previously attended another Paramedic Program?*

Yes

No

If you answered yes to the previous question, where?

Please indicate the location of the campus you would prefer to attend. The paramedic program may be offered at more than one location. (further information will be sent) *

Ozark Campus

Fort Smith Satellite Site

Russellville Satellite Site

Acknowledgment of Essential Functions-Paramedic*

Without reasonable accommodations

With reasonable accommodations (ADA requirements, learning disability needs, etc.)

By signing below, I acknowledge that I have read and understand the Essential Functions for the Paramedic Student. I believe to the best of my knowledge that I have the ability to learn and perform the Essential Functions: (Please check one)

I, the undersigned applicant to the Paramedic/EMS Program at Arkansas Tech University- Ozark Campus, understand that participation in a clinical experience is part of the Paramedic/EMS Program and that participation in a clinical experience includes working as a student at an affiliating agency. I understand that I will be responsible for all travel, meals, and lodging associated with clinical education. I further understand that affiliating agencies have the right to establish requirements for participation in clinical experience. I understand that I am responsible for providing copies of the documentation requested by the affiliated agency. I understand and agree that if I am rejected for participation in a clinical experience by an affiliating agency or if I refuse to submit to checks or tests that are required by an affiliating agency in order to participate in a clinical experience, I may be unable to complete my program of study and graduate from the Paramedic/EMS Program. I hereby release Arkansas Tech University- Ozark Campus, its employees, and all affiliating agencies from any liability with regard to my participation in a clinical experience and decisions made concerning my participation in a clinical experience.

Yes, I understand

No

Arkansas Tech University- Ozark Campus Paramedic/Emergency Medical Service Program uses external affiliated agencies for clinical experiences for our students. Affiliated agencies may impose requirements for students in order to be allowed access to clinical experiences. Students will be required to provide the following information to external affiliated agencies: Health Screening/Immunizations CPR Certification Criminal Background Investigation Drug Testing The student should maintain copies of the documents listed above. Affiliating agencies may require the student to provide a copy of the documentation.

I, the undersigned applicant to the Paramedic/EMS Program at Arkansas Tech University- Ozark Campus, understand that participation in the Paramedic/EMS Program does not guarantee the right to sit for the NREMT-Paramedic Exam. I also understand that participation in the Paramedic/EMS Program does not guarantee licensure as a Paramedic. I hereby release Arkansas Tech University- Ozark Campus, its employees, and all affiliating agencies from any liability with regard to my licensure as a Paramedic following successful completion of the program, and understand that any of the crimes listed in the Arkansas Act 666 of 1999 may bar me from practicing as a Paramedic after program completion.

Yes, I understand

No

Arkansas Tech University- Ozark Campus Paramedic/EMS Program prepares students through classroom and clinical experiences for entry level as a Paramedic. The Arkansas Department of Health Division of EMS has additional requirements a student must meet in order to sit for the National Registry of EMT’s Paramedic (NREMT) exam. Students must understand that the Criminal Background Investigation results may prevent the student from being able to sit for the NREMT-Paramedic Exam.

If you are not currently a Tech student please remember to complete an application for admissions and send all transcripts from previous schools attended as well as proof of two MMR immunizations to the Office of Student Services, 1700 Helberg Lane, Ozark, AR 72949). School application must be completed before submitting this application. I certify that the above information is accurate and complete to the best of my knowledge. I understand that falsifying information on any of the requested forms may be cause for immediate dismissal from the Paramedic/EMS program. *Name (acting as signature)

Date (mm/dd/yyyy)*