Fire & Rescue / Adult EMT Course

Transcription

1 Fire & Rescue / Adult EMT Course The $ tuition cost covers the course instructors, classroom / lab materials, the program textbook and all online companion products, the student s malpractice liability insurance, BLS manual, certification card, as well as one student uniform shirt. The EMT course is considered short term community education. Therefore this course does not meet required hours for financial funding, grants, A+, GI bills, or student aid. This is an individual out of pocket expense course. Tuition is structured into monthly payments to ease the burden of payment but, no refunds once payments are made to the program. 1. Prospective applicant will fill out the generic RTI /C application. If filling out the online application (Left Click to launch hyperlink), page five, Financial Aid does not apply to the EMT program and may be ignored. Do Not submit the standard $50.00 application fee with your application. This will be required later after pre-testing is completed. 2. Prospective applicant will go online to the Family Care Safety Registry submit their required fee ($14.25) in order to start process of criminal background search. 3. Submit the hard copy application to the RTC office, 500 Forum Drive, No Later than July 15 th. At that time you will sign the background release form and should have registered for or have already taken the TABE test. 4. Each prospective applicant must take the TABE test, passing with a tenth grade level in the reading comprehension and vocabulary sections. The test is free to the prospective applicant. Check on the EMT-Basic web page, with RTI/C Community Education, RTI/C Counselor at RTI, or with RTI/C Administration Secretary at RTC for TABE test times and availability (Left Click to launch hyperlinks). 5. Once the tests are graded, the prospective applicant will be notified of their score. Those who obtained a passing score will be encouraged to continue into the selection process. Where the $50.00 nonrefundable application fee, one standard resume, three reference forms (provided in the app pack or available from the RTC office) and one written letter why I want to be an EMT will be due no later than August 1 st to the RTC office, 500 Forum Drive. 7. Once the application fees, resumes, references, written letter, and the criminal background checks are gathered the information will be processed and potential students will be notified of their status no later than August 15 th. Selection status will be either Selected (in course), Alternate (if Selected does not fulfill all requirements alternates will be notified of selection change to Selected), or Disqualified (candidate did not pass all qualifications). 8. At this point Selected applicants that wish to attend the EMT class will be required to pay the nonrefundable $ acceptance fee to the program no later than August 15 th. Once payment is received, they will be considered enrolled in the EMT program. Alternate s will be contacted on a case by case basis if one of the Selected is unable to attend or comply with acceptance fees.

2 Payment Plan: Failure of or Non Compliance with payment schedule is grounds for Termination and removal from program. August 1 st - $50.00 nonrefundable application fee August 15 th - $ acceptance fee (this will go towards total tuition) September 15 th - $ monthly payment October 15 th - $200 monthly payment November 15 th - $200 monthly payment December 15 th - $200 - monthly payment January 15 th - $ monthly payment Student should budget for or have available to them; standard school supplies such as notebook, pencils, pens, binder, internet access, printer, and access. Additional cost in order to comply with clinical rotations: You will have up to October 1 st to obtain these items. (Failure / Non Compliance is grounds for Termination and removal from program) Urine drug screen 11 panel. By September 1 st. Physical exam, 2 - Two step Tb testing or chest x-ray, (Process may take up to a month to complete) Flu vaccination, Blood work regarding titer testing or re-vaccination if students shot records are not produced or are inadequate for clinical clearance. Uniform style pants, belt, leather boots or shoes, Travel to and from class / clinical. Meals during class/clinical If a student wishes to purchases items such as stethoscopes, blood pressure cuffs, scissors, etc. That would be student choice and not a requirement of the program. National Registry Testing Fees for EMT certification. Practical skills exam $70-$ Computerized written exam - $80.00 Contact Us For any questions about the program Click Here (Left Click to launch hyperlink). Rolla Technical Center / 500 Forum Drive / Rolla MO 65401/ (573) Fax (573) Rolla Technical Institute / 1304 E 10 th Street / Rolla MO 65401/ (573) Fax (573)

3 Fire & Rescue / EMT Program Requirements for Clinical Rotations Immunization and Drug Screening Guidelines Childhood Immunization records will be needed for the program If you are unable to find or access your childhood shot records, you will be required to obtain all shots and or proof of titers from a medical care provider of your choice. Immunization records should be presented by October 1 st of the program year. Clinical sites are no longer accepting a written statement from a physician about past illness. Proof of immunization dates or current titer testing is required. 1. TDap Booster Vaccination. This is a booster for Diphtheria, Tetanus and Pertussis given to adolescents and adults. 2. MMR - (Two shot series) - Measles, Mumps Rubella. Your records must show you have had two separate vaccinations; otherwise you will need to obtain them. 3. Varicella (Chickenpox). Need to have in your records your vaccination or you need to obtain a current positive titer test. 4. Hepatitis B Series Vaccination. This is a three shot series. If you have not had this series yet, you should consult your health care provider and start the process. 5. Seasonal Influenza Vaccination. The availability dates for this vaccination is seasonal. Please plan ahead, if your program starts in August. Having had the previous season s vaccination is good to get into class, but you may need another one to cover fall/winter of your program year. You should have no trouble obtaining the vaccination. 6. Tuberculosis Testing - (Two Step Process). This means that you need two separate PPD tests at least one week apart. Documentation for both tests should have the date test administered and the date resulted. (Process may take up to a month to complete) If you are unable to have the PPD skin test, you will need to have a chest x-ray done with physician evaluations report resulting no sign of tuberculosis. Urine Drug Screening consisting of an 11 panel screen for Fire & Rescue / EMT 1. Amphetamines 2. Barbiturates 3. Benzodiazepines 4. Benzoylecgonine - Cocaine metab 5. Marijuana metabolite 6. Methadone 7. Methaqualone 8. Opiates 9. Phencyclidine 10. Propoxyphene 11. Oxycodone / Oxymorphone

4 ADULT APPLICATION PACKET Admission Requirements include: Adult Application for Admission please refer to the program fact sheets or visit for application deadlines $50 non-refundable application fee ($25 for students returning in a consecutive year; allied health programs may have additional requirements and fees) Background check Register online at ($14.25 fee payable by debit or credit card) Registration must be completed at the time application is submitted Completion of the Authorization For Family Care Safety Registry Background Verification Form High School diploma or equivalent Passing score on pre-entrance exam Driver s license or birth certificate Social Security card (must be signed) Completion of the FAFSA (Free Application for Federal Student Aid) Eligible enrollees include graduates of accredited high schools or those who have the recognized equivalent of a high school diploma. Students seeking financial aid are required to have on file, with the Financial Aid office, a copy of a high school diploma or a recognized equivalent before any monies are disbursed. Any student with an outstanding balance from a previous enrollment period must make payment arrangements prior to readmission. All programs have a pre-entrance exam for new students. Allied health programs have a selection process that is specific to their program. For more information regarding selection processes, visit: The admissions policy is in compliance with the U.S. regulations for Title IV Federal Financial Aid; the Missouri Department of Elementary and Secondary Education; and the Commission of the Council on Occupational Education (COE), the accrediting agency for RTI/C. Rolla Technical Institute/Center

5 Rolla Technical Institute Rolla Technical Center 1304 East Tenth Street 500 Forum Drive Rolla, Missouri Rolla, Missouri Phone: (573) Phone: (573) Fax: (573) Fax: (573) Adult Application for Admission Name: Last, First, Middle (please print) Maiden and/or former Name(s) Nickname Address Current Mailing Address Cell Phone No. Home Phone No. Current Physical Address Work Phone No. Other Phone No. City, State, Zip Code County of Residence School District of Residence Program Selection #1 Program Selection #2 Are you a citizen of the US? Yes No If no, do you plan to gain citizenship? Yes No Have you had training in the Armed Forces? Yes No Have you ever been convicted of a misdemeanor or felony? Yes No If yes, please explain: Have you ever been convicted a law or ordinance regarding alcohol or drug usage? Yes No If yes, please explain: High School Diploma Yes No Graduation year: GED, HiSet, or other equivalency earned Yes No Year earned: Have you previously attended RTI/C? If yes, what program? Dates attended: What professional certifications or licenses do you hold? Highest level of education: High School Diploma or Equivalent Vocational/Technical Certification Associates Bachelors Other # Credit hours earned Name of School, College, University Attended Address, City, State, Zip Code Dates Attended Are you eligible for (please check all that apply)? VA Benefits A+ Scholarship Continued on back

6 Rolla Technical Institute/Center References: Please list below three professional references, such as an employer or teacher. Please give full name, complete address, and phone number. Name: Name: Name: Name Address Phone Numbers Home: Cell: Work: Home: Cell: Work: Home: Cell: Work: Confidential Waiver Release: I waive do not waive my right to see professional reference letters from those I have listed on this application or identified in the future as needed in accordance with Federal Law PL Contacts: Please list below three individuals, such as a parent/guardian or spouse, we may contact for follow-up purposes or in case of an emergency. Please give full name, complete address, and phone number. Name: Relationship: Name: Relationship: Name: Relationship: DOES THIS PERSON LIVE IN YOUR Name HOUSEHOLD Address Phone Home: Yes No Cell: Work: Home: Yes No Cell: Work: Home: Yes No Cell: Work: The information given on this form is true and complete* to the best of my knowledge. *Any misrepresentation, falsification or omission of information or any other attempt to deceive a school is cause for either denial or selection for admission or dismissal from enrollment; any future application(s) shall not be considered by Rolla Technical Institute/Center. Applicant Signature Date How to submit this application: Please submit application with the $50.00 non-refundable application fee ($25 for returning students in consecutive years) to: Student Services at RTC (medical programs) or RTI (all other programs). Applications may be mailed or submitted in person. We accept cash (exact amount), check, money order, or credit/debit cards for payment of the application fee. Statement of Non-Discrimination Rolla Technical Institute and Rolla Technical Center are affirmative action institutions. No person shall, on the basis of race, sex, creed, color, or disability, be subjected to discrimination in employment or in admission to any educational program or activity. As required by law, the district will provide equal access to district facilities and related benefits and services and will not discriminate against any group officially affiliated with the Boy Scouts of America, the Girl Scouts of the United States of America, or any other youth group designated in applicable federal law. RTI/C is fully accessible to the individual with a disability. *Inquiries regarding the implementation of this policy should be directed to: Title IX Section 504 Coordinator, Assistant Superintendent of Human Resources, Rolla Public School District No. 31, 500 A Forum Drive, Rolla, Missouri 65401, (573) Visit us on the web at:

7 Rolla Technical Institute Rolla Technical Center 1304 East Tenth Street 500 Forum Drive Rolla, Missouri Rolla, Missouri Phone: (573) Phone: (573) Fax: (573) Fax: (573) AUTHORIZATION FOR FAMILY CARE SAFETY REGISTRY BACKGROUND VERIFICATION Upon completion of the online registration with the Family Care Safety Registry at I authorize ROLLA TECHNICAL INSTITUTE/CENTER to verify my background information on the Family Care Safety Registry website. If I am selected into the program for which I am applying, this authorization will be valid for the length of the program at ROLLA TECHNICAL INSTITUTE/CENTER. I understand that my background information will be verified prior to admission and may be re-verified at any time while I am actively enrolled. I understand that my social security number will only be utilized to verify the background information on the Family Care Safety Registry. I hereby release ROLLA TECHNICAL INSTITUTE/CENTER from any claims, damages or liabilities of any kind that may directly or indirectly result from the use, disclosure, or release of such information by any person or party, whether such information is favorable or unfavorable to me, as a result of this background check. I have read the above, understand its contents, and voluntarily agree to its terms. Other first and/or last name(s) that the registry may be listed under Signature Date First Middle Last (Print Name) Social Security Number Birthdate (Month/Day/YYYY) Primary Program Applying For Secondary Program Applying For (if applicable) *Race/Ethnic Origin (please check all that apply) * The Rolla Public School District is required to make reports to the Office of Civil Rights and to the State of Missouri using the following Race/Ethnic categories. These are established by the State of Missouri and the U.S. Department of Education. Pacific Islander/Native Hawaiian White Black Asian American Indian Hispanic October 13, 2016 Please complete form and turn in with your application. Thank you.

8

9 ROLLA TECHNICAL CENTER 500 Forum Drive * Rolla, Missouri Phone (573) * Fax (573) Application Professional Reference Form APPLICANT: PROGRAM: The above named applicant has identified your name as a reference. Please complete this form and place it in the self-addressed envelope provided (sealed & initialed, please) and mail it as soon as possible. The applicant has or has not signed a waiver of confidentiality. All information you supply will be kept confidential. Please give us your candid opinion of this applicant s suitability for the duties in the medical profession. Please indicate your relationship to applicant: How long have you known this person? How well do you know above named person? In order to protect confidentiality, we ask that you send this completed form in the enclosed addressed envelope (seal & initial across the closure, please) and return to Rolla Technical Center* 500 Forum Drive* Rolla MO or fax to Please return this evaluation as soon as possible to allow the applicant to complete the application requirements. Following is a list of characteristics that we feel are required for a student to successfully complete training in our health programs. Please rate according to the following rating scale listed below: 5 Outstanding 4-More than Satisfactory 3-Satisfactory 2-Needs Improvement 1-Unsatisfactory NA-Not observed or no basis for judgment Abilities & Skills NA Descriptions Responsibility Accountable for one s actions Leadership Has capacity to direct activities of others Initiative Motivated to pursue actions independently Flexibility Capable of responding or conforming to changing or new situations Organization Arranges by systematic planning for optimal efficiency Self-Confidence Assured in one s abilities and skills Independent Work Completes tasks with minimal supervision Communication-Verbal Contributes knowledge and opinions in an articulate manner Communication-Written Expresses self clearly in writing Stress Response Maintains composure and able to function Attitude Positive approach to work and coworkers Manual Dexterity Ability to perform psychomotor skills Group Interaction-Peers/CoWorkers Ability to get along with peers and coworkers Teachers/Employers/Supervisors Ability to get along with teachers, employers, and supervisors Maturity Demonstrates common sense, tact, and empathy Knowledge Application Ability to apply academic theory to practice Decision Making Ability to analyze a problem and formulate a solution Dependability Follows through on assignments Attendance Prompt, punctual, and prepared Additional Information: Use to amplify or add to characteristics rated previously. Signature Date Please Print below Name: Title: Organization: Address: City State Zip Telephone: Fax: Thank you for your assistance. Reference Form Updated 10/11

10

11 ROLLA TECHNICAL CENTER 500 Forum Drive * Rolla, Missouri Phone (573) * Fax (573) Application Professional Reference Form APPLICANT: PROGRAM: The above named applicant has identified your name as a reference. Please complete this form and place it in the self-addressed envelope provided (sealed & initialed, please) and mail it as soon as possible. The applicant has or has not signed a waiver of confidentiality. All information you supply will be kept confidential. Please give us your candid opinion of this applicant s suitability for the duties in the medical profession. Please indicate your relationship to applicant: How long have you known this person? How well do you know above named person? In order to protect confidentiality, we ask that you send this completed form in the enclosed addressed envelope (seal & initial across the closure, please) and return to Rolla Technical Center* 500 Forum Drive* Rolla MO or fax to Please return this evaluation as soon as possible to allow the applicant to complete the application requirements. Following is a list of characteristics that we feel are required for a student to successfully complete training in our health programs. Please rate according to the following rating scale listed below: 5 Outstanding 4-More than Satisfactory 3-Satisfactory 2-Needs Improvement 1-Unsatisfactory NA-Not observed or no basis for judgment Abilities & Skills NA Descriptions Responsibility Accountable for one s actions Leadership Has capacity to direct activities of others Initiative Motivated to pursue actions independently Flexibility Capable of responding or conforming to changing or new situations Organization Arranges by systematic planning for optimal efficiency Self-Confidence Assured in one s abilities and skills Independent Work Completes tasks with minimal supervision Communication-Verbal Contributes knowledge and opinions in an articulate manner Communication-Written Expresses self clearly in writing Stress Response Maintains composure and able to function Attitude Positive approach to work and coworkers Manual Dexterity Ability to perform psychomotor skills Group Interaction-Peers/CoWorkers Ability to get along with peers and coworkers Teachers/Employers/Supervisors Ability to get along with teachers, employers, and supervisors Maturity Demonstrates common sense, tact, and empathy Knowledge Application Ability to apply academic theory to practice Decision Making Ability to analyze a problem and formulate a solution Dependability Follows through on assignments Attendance Prompt, punctual, and prepared Additional Information: Use to amplify or add to characteristics rated previously. Signature Date Please Print below Name: Title: Organization: Address: City State Zip Telephone: Fax: Thank you for your assistance. Reference Form Updated 10/11

12

13 ROLLA TECHNICAL CENTER 500 Forum Drive * Rolla, Missouri Phone (573) * Fax (573) Application Professional Reference Form APPLICANT: PROGRAM: The above named applicant has identified your name as a reference. Please complete this form and place it in the self-addressed envelope provided (sealed & initialed, please) and mail it as soon as possible. The applicant has or has not signed a waiver of confidentiality. All information you supply will be kept confidential. Please give us your candid opinion of this applicant s suitability for the duties in the medical profession. Please indicate your relationship to applicant: How long have you known this person? How well do you know above named person? In order to protect confidentiality, we ask that you send this completed form in the enclosed addressed envelope (seal & initial across the closure, please) and return to Rolla Technical Center* 500 Forum Drive* Rolla MO or fax to Please return this evaluation as soon as possible to allow the applicant to complete the application requirements. Following is a list of characteristics that we feel are required for a student to successfully complete training in our health programs. Please rate according to the following rating scale listed below: 5 Outstanding 4-More than Satisfactory 3-Satisfactory 2-Needs Improvement 1-Unsatisfactory NA-Not observed or no basis for judgment Abilities & Skills NA Descriptions Responsibility Accountable for one s actions Leadership Has capacity to direct activities of others Initiative Motivated to pursue actions independently Flexibility Capable of responding or conforming to changing or new situations Organization Arranges by systematic planning for optimal efficiency Self-Confidence Assured in one s abilities and skills Independent Work Completes tasks with minimal supervision Communication-Verbal Contributes knowledge and opinions in an articulate manner Communication-Written Expresses self clearly in writing Stress Response Maintains composure and able to function Attitude Positive approach to work and coworkers Manual Dexterity Ability to perform psychomotor skills Group Interaction-Peers/CoWorkers Ability to get along with peers and coworkers Teachers/Employers/Supervisors Ability to get along with teachers, employers, and supervisors Maturity Demonstrates common sense, tact, and empathy Knowledge Application Ability to apply academic theory to practice Decision Making Ability to analyze a problem and formulate a solution Dependability Follows through on assignments Attendance Prompt, punctual, and prepared Additional Information: Use to amplify or add to characteristics rated previously. Signature Date Please Print below Name: Title: Organization: Address: City State Zip Telephone: Fax: Thank you for your assistance. Reference Form Updated 10/11

14

15 DRUG SCREENING AUTHORIZATION FORM Student Name Address Social Security # The above listed student will pay TOMO Drug Screening Services the fee of $29.00 for an 11-panel drug screening as a requirement for admission to Rolla Technical Institute/Center. By signing this form, the student is giving permission to TOMO Drug Screening Services to release a copy of the drug screening results to Rolla Technical Institute/Center. It is understood that all test results are covered under the policy of confidentiality for Rolla Public Schools and cannot be released to any other person/institution/agency without written permission of the student. TOMO Drug Screening Services will follow its policies and procedures to secure the validity of the drug results. A PHOTO ID will be required before a sample is taken. Program (please select one) Practical Nursing Radiologic Technology Surgical Technology EMT Fire & Rescue Student s Signature (to be signed at time of drug screening) Date Rolla Technical Institute/Center 500 Forum Drive Rolla, MO Phone: Fax:

16

17 ROLLA TECHNICAL CENTER Physical Examination PROGRAM SCHOOL YEAR NAME DATE ADDRESS TELEPHONE AGE WT HGT TPR B/P PAST HISTORY: (ILLNESSES, OPERATIONS, INJURIES, DRUG ALLERGIES) EYES: VISION: R L WITH GLASSES: R L THROAT NOSE SINUSES ORTHOPEDIC CONDITIONS POSTURE HEART LUNGS ABDOMEN HERNIA RESTRICTIONS ON PHYSICAL ACTIVITIES Yes No Limited Identify & Describe Has this individual received treatment or hospitalization for emotional problems? Yes No If yes, when: Do you believe this individual is suitable physically and emotionally for safe practice in an allied health profession? Yes No If no, why: Is this person on any specific drugs for health maintenance? Yes No Name of medication Will this drug interfere with his/her performance as an allied health professional? Yes No M.D./D.O./N.P. NAME: (please print) M.D./D.O./N.P. SIGNATURE: ADDRESS: CITY, STATE, ZIP: TELEPHONE:

18

19 Rolla Technical Institute/Center Fire & Rescue / EMT Name: Date: Why I want to be an EMT / Firefighter. The Fire & Rescue program is interested in prospective students and the choices they make. In your own words describe why you have chosen the EMT or fire profession for your career. Use the entire page and make sure your writing is legible.