you are responsible for the content and timely completion...

You are responsible for the content and timely

completion of this application.

Manatee Technical College’s EMS programs are accredited by the National Committee on Accreditation of Educational Programs for the Emergency Medical Service Profession (CoAEMSP) and the State Bureau of Emergency Medical Services of Florida Department of Health

Additional Information:

Make copies of all of the required application items and keep your originals. We cannot make copies for you.

All MTC EMS students will be given a drug test during their program. A positive drug test will result in immediate withdrawal from the program without a refund.

Check-Off List

1. _______ M.T.C. Application ________ Student Consent Form 2. _______ Copy of an unofficial Transcript showing the date that the diploma / GED was received (you may also include a copy of the actual - high school diploma / GED certificate) 3. _______ Copy of Driver’s License 4. _______ FL Residency form with copies of 2 documents attached. 5. _______ Background Investigation: (Level 2 - Fingerprinting)– (office)________

6. _______ TABE Scores *_________or AS degree or higher Reading______ Total Math _______ Language ______ Date _____________ 7. _______ Physical Exam Date _____________ 8. _______ Immunization Dates – need copies of shot records 1. MMR Dates 1st___________ 2nd _____________

-OR- Positive Titer Date _____________

2. Tdap - within last 10 years ___________________

3. PPD (Tuberculosis Skin Test) 1st (anytime) _________________ 2nd (within 12 mths of start date) ____________ -OR- X-Ray ______________________ 4. Varicella (Chicken Pox) 1st __________ 2nd _____________ -OR- Positive Titer Date _______________

5. Hepatitis B 1st ________ 2nd _________ 3rd ___________ -OR- Positive Titer Date _______________ -OR- Signed Declination_______________ 9. ______ Letter of Intent (500 words or less – typed)

_____ *Self-Addressed Stamped Envelope- for Letter of Acceptance &

Registration Information.

10. Paramedic Only ____ CPR – Expiration Date __________

____ Copy of EMT Certificate ____ Documented 250 hours in EMS Field ____ Oral Interview

Application Form EMT-B Paramedic EMT-Basic & Paramedic Day ____ or Night____

Emergency Medical Services Programs

Manatee Technical College

Instructions: Read through the application process before filing this out. Please answer all questions completely, accurately and

truthfully. If an item does not pertain to you, please answer “N/A” (not applicable). Keep in mind that all information will be checked and verified. Misstatements, falsification or omissions may delay entrance into the Emergency Medical Services Program. Please print legibly. Your application cannot be completely

processed if the information is not legible.

Today’s Date: __________/__________/___________

Exact Legal Name (Please Print)

______________________________________________________________________________ Last Name First Name Middle Name Maiden Name

Social Security # _____-_____-______ Student ID #: ________________ Date of Birth: ___/___/___

Permanent Address (Residence):__________________________________________________________

City: _________________________ State: ____Zip Code: ____________ County: _________________

Current Mailing Address: ________________________________________________________________

City: _________________________ State: ___ Zip Code: ____________ County: ________________

Home Phone: ____________________________ Work Phone: _________________________________

E-Mail: _________________________________________ Cell Phone: __________________________

Emergency Contact: _____________________________________________

Relationship: __________________________________ Phone: ________________________________

Gender: Male Female Race: African-American Asian Caucasian

Hispanic Other: _____________________

Country of Birth: United States of America Other ________________________________________

Are you a U.S. Citizen? Yes No If Naturalized, what is your number? __________________

Are you Florida Residence? Yes No If No, what state? ___________________________

Do you possess a valid Driver’s License? Yes No

Driver’s License Number: ______________________ State Issued: ___Expiration Date: ______

Arrest History

If you answer yes to any of the following questions, please explain. You may need to provide copies of any relevant

paperwork (reports, release papers, etc.) Attach a separate sheet of paper if you need more space.

Have you ever been arrested (adult or juvenile)? Yes No

Have you ever been arrested for a felony charge? Yes No

Have you ever been arrested for a drug or alcohol violation? Yes No

Have you ever been convicted of any charges? Yes No

Have you ever been issued a traffic citation? Yes No

If you answered YES to any questions, please explain/describe:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Failure to provide true and accurate statements will result in your application being disqualified for consideration.

School History Please provide information for all school attended, beginning with High School/GED.

1. High School: ______________________________________City/State _________________________

Diploma Received: _________________________________ Date of Attendance: ________________

2. School: __________________________________________City/State _________________________


Number of Credits Completed: _______







Employment History Beginning with present employment, list your three most recent employers, including summer and part-time work while attending

school. Addresses must be complete.

1. Dates of Employment: From: ___________________ To: ________________________ Month/Year Month/Year Name of Company: __________________________________________________________________

Street Address: _____________________________________________________________________

City, State, Zip Code: ________________________________________________________________

Telephone: ______________________________ Supervisor: ________________________________

Position held and duties: _____________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

2. Dates of Employment: From: ___________________ To: ______________________ Month/Year Month/Year Name of Company: __________________________________________________________________

Street Address: _____________________________________________________________________

City, State, Zip code: _________________________________________________________________



__________________________________________________________________________________

__________________________________________________________________________________

3. Dates of Employment: From: ___________________ To: ______________________ Month/Year Month/Year Name of Company: __________________________________________________________________

Street Address: _____________________________________________________________________

City, State, Zip code: _________________________________________________________________



__________________________________________________________________________________

__________________________________________________________________________________

Specialized Training, Experience & Coursework

Please include a copy of your transcript and copies of any relevant certifications with this application. You will be given

credit for training and course-work that can be verified with a valid certificate or a transcript.

Provide dates, institution/agency and city for any that applies to you:

CPR Training: ________________________________________________________________________

First Responder (40hr): _________________________________________________________________

Anatomy & Physiology: ________________________________________________________________

Medical Terminology: __________________________________________________________________

First Aid: ____________________________________________________________________________

Fire School: __________________________________________________________________________

Additional Fire: _______________________________________________________________________

Fire Volunteer: ________________________________________________________________________

Hospital Employment: __________________________________________________________________

Hospital Volunteer: ____________________________________________________________________

Law Enforcement: _____________________________________________________________________

Military Training: ______________________________________________________________________

Other: _______________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ (If there is further experience not yet mentioned that you would like included in your application, please add on a separate piece of paper or attach a

resume/CV)

Paramedic Applicants:

Do you have a valid and current State of Florida EMT certificate? Yes No

Certificate Number: ____________________________

Have you completed a college level course in Anatomy and Physiology? Yes No

When and where did you complete it? ______________________________________________________

Have you completed a college level course in Medical Terminology? Yes No

When and where did you complete it? ______________________________________________________

EMS Programs

STUDENT CONSENT FORM

As a student enrolled in a Manatee Technical College EMS Program, I understand that the required clinical experiences in various health care arenas may expose me to environmental hazards and infectious diseases including, but not limited to, tuberculosis, hepatitis B and HIV (AIDS). Neither Manatee Technical College nor any of the clinical or internship organizations used for clinical or internship experience assumes liability if a student is injured or exposed to infectious disease in the clinical facility or EMS unit during assigned clinical or internship experiences, unless the injury/exposure is a direct result of negligence by Manatee Technical College or the clinical or internship organization. As a student, I understand that I am responsible for the cost of health care for any personal injury/illness that occurs during my education. Manatee Technical College strongly recommends that students purchase their own health insurance. Every EMS student is required to carry liability insurance while enrolled in clinical courses. This insurance is automatically purchased by the Manatee County School Board. I also understand my responsibility to strictly maintain the confidentiality of all client information, whether personal or medical, as well as keep confidential any information related to the clinical facility. As an EMS student, I clearly understand and fully agree, under the penalty of law, that I will never inappropriately access, disclose or reveal in any way, either directly or indirectly, any information from a client’s record or related to the care and treatment of any client, except, as needed, to authorized clinical staff. I further agree not to reveal any confidential information about the clinical facility to any third person. Each student also is responsible for adhering to the policies and procedures of the Manatee Technical College EMS Program as well as Manatee Technical College as noted in the student handbooks. My signature on this form confirms that I understand and assume responsibility for the inherent risks involved in being a student in an EMS Program at Manatee Technical College, and for adhering to the above policies. ______________________________ _______-______-________ Student Name (please print) Student’s SS# ______________________________ ______________________ Student’s Signature Date _______________________________ _______________________ Parent/Guardian Name if minor Parent/Guardian Phone # ________________________________ _______________________ Parent’s Signature (if minor or in high school) Date

Residency Florida Classification To receive in-state tuition rates, students must prove that they have maintained Florida residency for at least 12 complete months prior to their first day of school. (See approved documents listed on back).

Dependent or Independent Student? Please check the appropriate classification

_____ I am an independent person and have maintained legal residence in Florida for at least 12 months. A student who meets any of the of following criteria shall be classified as an independent student for the determination of residency for tuition purposes:

1. The student is 24 years of age or older by the first day of classes of the term for which residency status is sought at a Florida institution;

2. The student is married; 3. The student has children who receive more than half of their support from the student; 4. The student has other dependents who live with and receive more than half of their support from the student; 5. The student is a veteran of the United States Armed Forces or is currently serving on active duty in the United States Armed Forces

for purposes other than training; 6. Both of the student’s parents are deceased or the student is or was (until age 18) a ward/dependent of the court; 7. The student is working on a master’s or doctoral degree during the term for which residency status is sought; or 8. The student is classified as an independent by the financial aid office at the institution.

Applicants under age 24 can claim independence with proof of acceptable income and based on strict guidelines from Florida Statues. See: http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=1000-1099/1009/Sections/1009.21.html

_____ I am a dependent person and my parent or legal guardian has maintained legal residence in Florida

for at least 12 months.

_____ I am a dependent person who has resided for five years with an adult relative other than my parent or legal

guardian, and my relative has maintained legal residence in Florida for at least 12 months. (Required: A copy of most recent tax return on which you were claimed as a dependent or other proof of dependency).

_____ I am married to a person who has maintained legal residence in Florida for at least 12 months. I have now

established legal residence and intend to make Florida my permanent home. (Required: A copy of marriage certificate, claimant’s voter registration, driver’s license and vehicle registration). Residence in Florida must be as a bonafide domicile rather than for the purpose of maintaining a residence incident to enrollment at an institution of higher education. To qualify as a Florida resident, you must be a U.S. Citizen or an eligible non-citizen. Living in or attending school in Florida will not, in itself, establish legal residence. Students who depend on out-of-state parents for support are presumed to be legal residents of the same state as their parents.

Person claiming Florida Residency must complete this section and sign.

If student is a dependent, documents and signature must be from a parent/guardian.

Include photocopies of two documents from approved list on back.

Name of student _________________________________________________ Name of person claiming FL residency ________________________________ Relationship to student_________________ I do hereby swear or affirm that the above named student meets all requirements indicated in the checked category above for classification as a Florida resident for tuition purposes. I understand that a false statement in this affidavit will subject me to penalties for making a false statement pursuant to 837.06, Florida Statues, and to Rule 6C-7.005 F.A.C.

Signature of person claiming FL Residency _____________________________________________ Date ____________________

In-State Tuition for MTC Students

State statutes require that all adult students who attend MTC pay for tuition rates based on whether or not the student, or parent/guardian for a dependent student, has resided in Florida for the past 12 months.

What is Proof of Residency?

Two documents are required. At least one (1) must be from First Tier; the second document may also be from First Tier or may be from Second Tier. First Tier

Florida Driver license or State of Florida identification card

Florida voter registration card

Florida vehicle registration

Proof of purchase of a permanent home in Florida that is occupied as a primary residence of the claimant

Transcripts from a Florida high school for multiple years if Florida high school diploma or GED was earned within last 12 months

Proof of permanent full-time employment in Florida (one or more jobs for at least 30 hours per week for a 12-month period)

Second Tier

A Florida professional or occupational license

Florida incorporation

Documents evidencing family ties in Florida

Proof of membership in Florida-based charitable or professional organizations

Utility bills and proof of 12 consecutive months of payments

Lease agreement and proof of 12 consecutive months of payments

State or court documents evidencing legal ties to Florida

Benefit histories from Florida agencies or public assistance programs

Declaration of domicile in Florida (12 months from the date the document was sworn and subscribed as noted by the Clerk of Circuit Court)

Unacceptable Documents that May NOT be Used

Hunting or fishing licenses

Library cards

Shopping club/rental cards

Birth certificate

Passport

Social Security Card

MANATEE TECHNICAL COLLEGE

HEALTH PROGRAMS

PRE-ENTRANCE PHYSICAL EXAMINATION

This section to be completed and signed by applicant before examination and reviewed with physician.

Name __________________________________________ Phone ___________________

Address____________________________________________________________________________________________

Street No. or P.O. Box City State Zip Code

Medical History: Do you now have or have you ever had any of the following:

Condition ………… Yes No Condition ………… Yes No Condition ………… Yes No

Asthma

Epilepsy Tuberculosis

Alcoholism

Fainting Spells Varicose veins

Arthritis

Heart condition High Blood Pressure

Back Trouble

Hepatitis Severe Headaches

Drug dependency/

Addiction

Hypertension Emotional/Psychiatric

Disturbance

Diabetes

Kidney disease

If you answered “Yes” to any of the above, please give details

________________________________________________________________________________

________________________________________________________________________________

List any allergies__________________________________________________________________

Have you had any serious injuries or operations? ________________________________________

List with approximate dates_________________________________________________________

List any medications taken regularly: _______________________________ __________________

In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired practitioner program _______Yes _______ No. If Yes, please explain

_____________________________________________________ ________

In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder or impairment? ____Yes

___No If yes, please explain

_________________________________________________________________________________________

In the last 5 years have you been treated for or had a recurrence of a diagnosed physical impairment? ___Yes ___No If

yes, please explain ___-

_________________________________________________________________________________

In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive disorder? ____Yes ___No If

yes, Please explain ______________________________________________________________________________

Student/Applicant Signature: ___________________________________

Applicant Name: ________________________________________________

Hgt ____________Wgt ____________Blood Pressure______________Temp.__________Pulse___________Resp.___________

Visual Acuity: Right with / without corrective lenses _______________/_________________

Left with / without corrective lenses _______________/_________________

Are there any abnormalities of the following systems? Describe fully on separate sheet and attach

System ……………………… No… Yes.. Comments………………………………………………………………

1. Respiratory

2. Cardiovascular

3. Gastrointestinal

4. Hernia

5. Eyes/Ears

6. Genitourinary

7. Musculoskeletal

8. Metabolic/Endocrine

9. Neuropsychiatric

10. Skin

Name of examiner: _______________________________________ Phone Number: ___________________________

Address: _______________________________________ City: ________________________ State: ________ Zip: ______________

Signature of examiner: __________________________________________ Date of exam: ___________________________

Physician or Nurse Practitioner

Immunizations Date Given or Results Signature of Doctor or Nurse

Measles/Mumps/Rubella

1st MMR

2nd MMR

Or Positive Titer (for all 3) with lab report

Tdap (within last 10 yrs)

Tuberculosis PPD Skin Tests (for health care

providers)

#1

#2

OR QuantiFeron Gold

OR statement of negative chest x-ray and statement of

“no current symptoms” (within 2 years)

Varicella (Chicken pox)

1st varicella

2nd varicella

OR positive titer with Lab report

Hepatitis B (strongly recommended, series of 3)

Current Flu Shot (in flu season)

NOTE: The Hepatitis B vaccine is highly recommended for the profession for which you are training. Clinical/field internships may expose you to carriers of the

Hepatitis B strain.

PROOF OF IMMUNITY:

1) Documentation of immunization will consist of a written dated statement by a physician on this form or on his/her stationary that specifies the date

seen and states that the person has had the specific vaccines listed above. All immunizations are required regardless of age. 2) Laboratory (serology) evidence of measles, mumps, rubella and chicken pox immunity would be acceptable Lab report required

HEPATITIS B VACCINE DECLINATION FORM

Manatee Technical College

Emergency Medical Services

I understand that due to my occupational exposure to blood or other potentially infections materials, I may be at risk for acquiring hepatitis B virus (HBV) infection. I have been advised to be vaccinated with the hepatitis B vaccination at my own expense. However, I decline the hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the hepatitis B vaccine, I can get the vaccination series at my own expense. ___________________________ (Student printed name) ___________________________ ___________ (Student signature) (Date) ___________________________ ___________ (Instructor signature) (Date)