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Paramedic Education Program Application
Applicant:
First Name:   
Last Name:   
Contact Information:
Home Address:   
City:   
State:   
Zip:   
Phone:   
E-mail:   
Length of time actively involved in EMS:
 
 
 
 
 
Initial EMT Education:
Program Name:   
Location of Program:   
Primary Instructor:   
Start Date:    
Application for the following class:
 
 
 
 
Current level of EMT certification:
 
 
Massachusetts EMT Certification:
EMT #:   
Original Date of Issue:    
Expiration Date:   
National EMT Certification:
NREMT Cert #:   
Original Date of Issue:    
Expiration Date:   
Other State EMT Certification:
EMT #:   
State:   
Original Date of Issue:    
Expiration Date:   
Other Pertinent Certifications
(if applicable, you may list up to six)
 Other pertinent Certifications

#1

  

#2

  

#3

  

#4

  

#5

  

#6

  
Please answer the following questions.
Note: If you answer "yes" to any of the following questions, please explain in the text box below.
 YesNo
Has your EMT certificate or authorization to practice ever been revoked or suspended?
Have you ever falsified training records or requirements related to any EMS certification?
If you answered "yes" to any of the last questions, please explain in the box below.

High School Education:

Name:   
Location:   
Year graduated:
   

College/University:

Name:   
Location:   
Major / Degree:   
Year graduated:
   

Graduate Program:

Name:   
Location:   
Major / Degree:   
Year graduated:
   

Current Employer:

Company / Service
   
Position:   
Length of Employment:   
Supervisor:   
Contact Information:
   
Reference #1
Name:   
Relationship:   
Title / Position:   
Email Address:   
Phone Number:
   
Reference #2:
Name:   
Relationship:   
Title / Position:   
Email Address:   
Phone Number:
   

Program Expectations

Prior to submitting your application, please acknowledge that you understand the following expectations:

 YesNo
I understand that this program requires me to act professionally at all times.
I understand that this program requires me to be on-time for all of my classes, clinical rotations, field shifts, and other obligations associated with this program.
I understand that this program requires me to be subject to drug and / or alcohol screening, the results of which may affect my admission and / or continued participation in this program.
I understand that this program requires me to be subject to criminal and / or background checks, the results of which may affect my admission and / or continued participation in this program.
I understand that this program requires me to dedicate long hours, including weekends and holidays.
I understand that this program requires me to perform strenuous tasks.
I understand that the requirements of this program may impact my work schedule.
I understand that the requirements of this program may impact my personal and social life.
I understand that this program requires 100% attendance.
I understand that I must dress in clean, issued uniforms for all classes, clinical rotations, and field shifts.
I understand that I must meet certain grooming standards for participation in this program.
I understand that this program requires a minimum of 600 classroom (didactic and laboratory) hours.
I understand that this program requires a minimum of 250 clinical (hospital) hours.
I understand that this program requires a minimum of 250 field (ambulance) hours.
I understand that there is no college credit awarded for participation in this program.
I am aware of the advertised tuition of the program and that I am responsible for all costs and tuition of the program, unless otherwise specified.
I understand that there may be additional costs involved in participating in this program.
I understand that this program prepares me for licensing and / or credentialing as paramedic, but does not guarantee lecensure or credentials.

I have read and understand the functional job description of a Paramedic

Upon receipt of this application, you will be contacted by Pro EMS Center for MEDICS staff.

If you have any questions, please contact us at 617-682-1811

We accept students on a rolling basis for all programs.

A $75 application fee is due upon submission of your application.  Payments should be made through PayPal.

(https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=D7ALPB6PLQ6TE)

The Pro EMS Center for MEDICS does not discriminate on the basis of race, religion, ethnicity, age, sex, nationality, or sexual orientation.

I hereby attest and affirm that I am committed to this EMT-Paramedic education program and will make sufficient time available for its completion. I attest that I will pay all fees and tuitions incurred while enrolled in this program as specified by my financial agreement. I also attest to the fact that all information provided by me is true and correct to the best of my knowledge. (Any attempt to offer incorrect or fraudulent information will result in immediate withdrawal of this application, termination from the program, and forfeiture of future program acceptance.)

Please contact and review this agreement with your own legal counsel if you have any concerns.

Electronic Signature:
Date:
Would you like a copy of this application e-mailed to you?
 
 


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