1. Be at least 18 years of age at the start of the program. 2. Be an Emergency Medical Technician, preferably with at least one year's experience.

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1 PARAMEDIC PRE-PROGRAM PREREQUISITES 1. Be at least 18 years of age at the start of the program. 2. Be an Emergency Medical Technician, preferably with at least one year's experience Submit an Admissions Application and a copy of their medical insurance, current liability insurance, driver's license, and their high school diploma or GED Certificate. Complete a personal health history form and submit a physician examination form completed and signed by a family physician. 5. Complete the college assessment test and an EMT Skills review test. 6. Successfully complete an oral interview conducted by the College's Paramedic Program staff. 7. Have paid all admission fees Have submitted payment for textbooks or have made payment arrangements with the Business Office. Have ordered and paid for the paramedic uniform or have made payment arrangements with the Business Office. 10. Have filled out the necessary Financial Aid applications All students are required to pay materials/registration fees prior to the start of class. Any student not paying these fees in full, will not be admitted into class. No exceptions will be made.

2 APPLICATION FOR ADMISSION PERSONAL INFORMATION NAME: SS#: Address DOB AGE PHONE NUMBER Home Work DATES Date of Interview By Date of Acceptance By GENERAL INFORMATION EMT CERTIFICATE EXP DATE STATE ALS AFFILIATE ACADEMIC Pre-Admission Test Date Interview Date Paramedic Training Institute Fax

3 LACKAWANNA COLLEGE PARAMEDIC TRAINING INSTITUTE HEALTH INFORMATION FORM EVERY APPLICANT FOR ADMISSIONMUST COMPLETE THIS FORM: Name Sex Address Phone Date of Birth PERSONAL HISTORY 1. Have you lived in close contact with anyone who had Tuberculosis: No Yes Explain 2. Have you ever had any of the following? None check here Rheumatic Fever/ Diphtheria Allergies (specify) Cholera Poliomyelitis Heart Disease Gland Trouble Hernia Hay Fever/Asthma Tuberculosis Diabetes Food Sensitivity Speech Disorder Epilepsy Recurrent Headaches Kidney Disease Scarlet Fever Convulsions/Blackouts Nervous Tendencies Bone/Joint Trouble If checked,please explain: LAST DATES OFIMMUNIZATIONS Small Pox Tetanus Toxoid Polio Tuberculosis 3.Among your blood relatives, is there any history of /or present illnesses from the following? Cancer Diabetes Tuberculosis Stroke Allergies Convulsions Nervous Heart Disease High Blood Pressure If checked, what condition, which relative?

4 4. Dates of significant injuries or operations which you have had: If none, check here: Injury or operation? Date Explain 5. Based on your most recent physical examination, do you have any physical limitations which would effect your participation in the classroom or activities such as physical education? If no, check here Yes, explain 6. Date of last chest x-ray? Findings 7. Do you presently feel the need for Psychological or Health Counseling? If not, check here Check services desired: Health Counseling Psychological Counseling EMERGENCY INFORMATION 1. In case of emergency, person to be contacted: Name Address Phone Relationship 2. In time of an emergency, I here by authorize and direct the college to send me to the hospital or physician most readily accessible, and/or to administer necessary emergency care. Student s Signature Date 3. Type of Insurance/Plan Number

5 MEDICAL HEALTHFORM Student Name REQUIRED MEDICALIMMUNIZATIONS(to be completed byphysician) Tetanus (booster every 10years) Polio Measles-Mumps-Rubella (MMR) *Hepatitis B Vaccine Date of last immunization Date of last immunization RECOMMENDEDMEDICAL IMMUNIZATIONS Influenza Typhoid If the physician feels certain immunizations are not necessary, please include a statement to that effect. Physicians Signature Date *Note:If student declines to be immunized against HepatitisB, a declination statement must be provided.

6 HEPATITIS B DECLINATION STATEMENT I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) injection. I have been given the opportunity to vaccinate with Hepatitis B vaccine and decline at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B Vaccine I will do so at my own cost. Student Signature Date Paramedic Training Institute Fax

7 FINANCIAL INFORMATION In addition to previous program prerequisites, students must fill out appropriate financial aid applications. An appointment can be made by calling the Lackawanna College Financial Aid Office at Registration Fee $ (Fee is non-refundable and must be submitted with the application. Testing will not be scheduled until fee is paid.) Credentialing Fees $710 (Fee is non-refundable and due upon acceptance into program) Books and Clinical Software $ (Fee is non-refundable and due upon acceptance into the program.) All fees, including registration form and books must be paid in full before the semester begins. First Semester $6, Second Semester $6, Tuition: Total cost for the program $15, *Students who qualify may receive funding through Financial Aid to cover the full cost of tuition.

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