August 6, 2015 Dear EMT Student Applicant: We applaud yur desire t investigate becming an Emergency Medical Technician (EMT). Our agency has ver 35 years experience prviding EMS t the Twn f Friday Harbr, San Juan Island and the islands f Brwn, Stuart, Jhns, Speiden, Pearl and Henry. We functin as a municipal third service 9-1-1, tax supprted EMS/MedEvac system under the San Juan Cunty Public Hspital District N. 1 serving the residents and visitrs f ur district as well as the waterways and ther nn-ferry served islands f San Juan Cunty when requested. We are natinally accredited using a mixed prvider mdel with award winning patient satisfactin and natinally certified/recgnized leadership. Yu will need t purchase EMT bks (abut $250, reimbursed at the cmpletin f the class) and attend all training, cmplete all hmewrk, practical classes, and sessins. The EMT curse begins Nvember 4, 2015 with mandatry prerequisites cmpleted befre the class start date. This curse requires attendance f all scheduled Wednesday nights and Saturday days thrugh April, 2016. Ttal curse includes 190 instructin hurs and requires additinal individual study and practice time. This packet will help yu navigate the applicatin prcess. Please read it carefully, cmplete it accurately, and return all materials, in persn, t the address n the cver letter. Persnnel are generally in the ffice Mnday t Thursday during nrmal business hurs. A subset f all applicants will be scheduled fr an interviews/agility test. The prcess is highly cmpetitive and will include the written applicatin, physical agility exam and current immunizatin recrd, criminal/driving, drug and emplyment backgrund checks. Questins abut this prcess can be directed t Weyshawn Kns r Cady Davies at training@sanjuanems.rg r by phne at 360-378-5152. Student candidates will be selected based n multiple criteria including, but nt limited t, applicatin materials, examinatin scres, test results, backgrund checks, gegraphical lcatin, ability t respnd t calls, and face t face interviews. Successful acceptance int the EMT class des nt guarantee a psitin as an EMT with San Juan Island EMS and MedEvac upn cmpletin f the curse. COMPLETED APPLICATION DUE MONDAY, SEPTEMBER 14, 2015 BY 5 PM AT PHYSICAL ADDRESS BELOW. Fr further infrmatin, please g nt the web at www.sanjuanems.rg. We wish yu success in yur applicatin.
Minimum Requirements t Apply We value yur time and interest. Yu will need t meet ALL f the fllwing criteria: 1. Willing t cmplete all aspects and requirements f the class. 2. Full-time, permanent resident f San Juan Island with the expectatin t remain a full-time resident fr the next tw years fllwing graduatin. 3. Able t d a physically and emtinally difficult jb f prviding care t acutely ill and injured peple, in dangerus situatins, requiring quick and clear thinking with physical dexterity and strength. 4. 21 r lder (due t insurance requirements). 5. High schl graduate r GED. 6. Nt becme a member f any ther public safety agency while a student r during yur first year past prbatin because f the extensive training and rientatin requirements. 7. Be legally emplyable in the United States. 8. Valid Scial Security Number and pssess a valid Washingtn State Driver License with less than 6 pints and n cnvictins fr DUI. 9. N felny cnvictins that wuld prevent yu frm becming certified with the State f Washingtn. 10. Free frm addictin t any prescribed, recreatinal, and/r illegal drugs r substances. We have a zer tlerance plicy. 11. Be able t cmmit and cmplete the entire curse with a willingness t then apply t becme an EMT with ur agency with full supprt frm yur immediate family. 12. Serve a minimum f tw years past the initial prbatinary perid r repay San Juan Island EMS the amunt f $2,500 fr the cst f the training. 13. Submit t a physical examinatin including drug screening exam prvided at the cst f the district. 14. Underg a thrugh criminal backgrund and driver check thrugh available law enfrcement inquiries. 15. Purchase yur textbks which cst apprximately $250 (reimbursed at the end f yur prbatinary perid upn cmpletin). 16. Becme a certified Wilderness EMT within 2 years f cmpleting prbatin. (Wilderness training prvided by the agency). 17. Cmplete all ther requirements t maintain yur status as an active EMT. 18. Pssess a genuine caring fr the residents and visitrs in ur cmmunity and act prfessinally and with cncern fr peple s safety and privacy at all times. I recgnize that this is an applicatin fr entrance int the EMT class nly and nt an applicatin fr emplyment r vlunteering with San Juan Island EMS and MedEvac. I agree t pay fr the cst f my bks befre class begins. Having read the abve, I, agree t fulfill the requirements and submit t the terms f reimbursement fr self-selected early terminatin r terminatin frm the curse with cause. Signature f Applicant Date Witness Date
Checklist (T Be turned in with Applicatin) Applicant Name: Meet Minimum requirements Cmpleted Applicatin with signatures and witness signatures Cpy f High schl diplma r GED Cpy f Valid Scial Security Card Cpy f Washingtn State Driver License Cmpleted Backgrund Check Waiver with witness signatures Immunizatin Frm Cmpleted
Basic Demgraphic Infrmatin TODAY S DATE DATE TURNED IN NAME LAST FIRST MIDDLE ADDRESS MAILING Physical Address (IF DIFFERENT) EMAIL ADDRESS: TELEPHONE_(hme) (cell) DATE OF BIRTH / / SOCIAL SECURITY NO. (Attach a legible cpy) CURRENT WA STATE DRIVERS LICENSE NO. Exp. Date: (Attach a legible cpy) D yu have any physical r psychlgical prblems that culd affect yur ability t perfrm the wrk f an EMT? YES NO WOULD YOU BE ABLE TO SIGN UP FOR MULIPLE 6 HOUR SHIFTS PER MONTH? DAYS ONLY NIGHT AND DAY SEASON DEPENDENT NIGHTS ONLY CERTAIN DAYS OF THE WEEK D yu have any past medical experience? If yes, please explain. Are yu currently affiliated with any ther public safety agency r vluntary cmmunity grup(s)? In 100 wrds r less, tell us why yu want t becme an EMT with San Juan Island EMS. (Use back if necessary)
Criminal/Driving Backgrund Waiver and Release TODAY S DATE : I, d hereby authrize San Juan Island EMS and MedEvac t btain cmplete driver, educatinal, military service, prir licensing, wrk recrds, and criminal recrds and histries and any ther infrmatin cncerning my previus emplyment r vlunteering. This may include but nt limited t WATCH, NCIC, San Juan Cunty Sheriff Recrds, Military Discharge Recrds, State and Federal recrds, emplyment recrds, vlunteering recrds, and educatinal recrds. I hereby release all parties and persns cnnected with any request fr infrmatin frm all claims, liabilities, and damages fr whatever reasn arising ut f such infrmatin gathering r infrmatin received. NAME LAST FIRST MIDDLE ADDRESS MAILING Physical Address (IF DIFFERENT) TELEPHONE DATE OF BIRTH / / SOCIAL SECURITY NO. (Attach a legible cpy) CURRENT WA STATE DRIVERS LICENSE NO. (Attach a legible cpy) Signature f Applicant Date Witness Date
Immunizatin Recrd fr San Juan Island EMS and MedEvac Name: Date f Birth: Please fill in the dates fr all yur current immunizatins yu have received in the apprpriate space given belw. IMMUNIZATIONS REQUIRED BEFORE CLASS STARTS: (Applicant Respnsibility) If yu dn t knw when yur last MMR was, yu may get a MMR titer (which is an immunity test) TDAP MMR #1 MMR#2 MMR Titer result MMR BOOSTER IMMUNIZATIONS REQUIRED DURING r AFTER CLASS: (Prvided by Agency) TB TEST Hep B #1 Hep B #2 Hep B#3 Hep B Titer (HBsAb) Hep B Bster Flu Sht OTHER IMMUNIZATIONS YOU MAY HAVE RECEIVED: Name Date: I, state that the fllwing recrds are accurate and up t date. I understand that further dcumentatins may be requested by San Juan Island EMS.
Signature Date EMT Student Candidate Physical Agility (Fr Infrmatin Only) Pre evaluatin candidate fr Heart Rate, Bld Pressure, Respiratins and Warm up. Stage 1: Equipment Carry Maximum time 5 minutes The candidate is t carry 1 fully stcked medical bx (pelican case), 1 cardiac mnitr, and 1 airway bag (n back) up and dwn 3 stries f stairs safely. Candidate is allwed t set dwn equipment 1 time (max 5 secnds) withut pint deductin. Time begins when the Candidate lifts equipment ff flr. Nte: Airway bag can be pre-psitined as backpack. Lifting and carrying begins as sn as the 5 minutes is up r candidate is ready whichever is first. Each piece f gear is less than 30 lbs. each. Stage 2: Lifting and Carrying Task 1: N time limit Candidate will be paired with an EMT partner (able t cmplete all EMS related physical tasks) and will be required t mve rescue manikin, 185 lbs. frm seated psitin t stair chair and up ne stry and dwn the stairs safely. Task 2: Candidate will be paired with same EMT partner t package patient nt backbard using spider straps. Tw mre EMT s r Firefighters will arrive t assist in lifting patient and carrying up tw flights f stairs then place the patient dwn and switch carrying ends befre cntinuing dwn tw flights f stairs safely. Patient will then be placed n ct and laded int the ambulance. Nte: Candidate will carry either head f patient r ft f backbard. EMT skills are nt required fr this statin. EMT partner will instruct and assist. Mid evaluatin f candidate HR, BP, RR Stage 3: Rescue Mannequin Drag 2 minutes maximum Candidate will pick up the 185 lb. mannequin by squatting dwn and reaching arund the rescue mannequin with bth arms under the mannequin s arm pits. The candidate will then drag the mannequin 10 feet and set the mannequin dwn gently. The time will start when the mannequin s buttcks are ff the grund and time will stp when the candidate and the mannequin bth crss the line. The candidate may stp t repsitin hands but must nt drp the mannequin. Stage 4: Cardi Walk 15 minutes maximum The candidate will walk a distance f 1 mile with a weighted vest f 25 lbs. Cl dwn perid San Juan Island Fitness www.sanjuanislandfitness.cm and Xteme Fitness www.xtremefitnesssji.cm have bth been made aware f the requirements f the candidate test requirements and may be a resurce, if yu desire. Any cst r use f these facilities r services is strictly vluntary and is nt required prir t the exam. During all lifting evlutins, any unsafe actins will result in failure.