NWSCC EMS Program Application

1. I certify that I meet the minimum educational requirements for the program in which I am enrolling. I further understand and agree that specific programs such as LPN, RN, DMS, RAD, MAT, and EMS have additional admission requirements. It is my responsibility to comply with those requirements.

2. I understand that all admissions materials must be submitted prior to the deadline specified by the EMS Program to be eligible for admission into the Paramedic Program.

I hereby acknowledge that I am nineteen years of age or older, or that if I am under the age of nineteen I am signing this release with the written consent of my parent(s) or legal guardian(s). I further acknowledge that I fully understand the contents of this release and that I am signing it voluntarily.

As a student or a prospective student of the Emergency Medical Services Program at Northwest Shoals Community College, I am aware of the risk of personal illness, injury, or death which is inherent in my participating in the EMS clinical and/or ambulance rotation activities.

Upon full awareness and consideration of the risks which I assume in participating in hospital, emergency department, ambulance, rescue, or other clinical rotations or laboratory activities, I hereby agree to release Northwest Shoals Community College and its instructors, officials, agents, representatives, preceptors, and employees from any liability for any type of illness or injury, including one resulting in my death, which is incurred during a period in which I am participating in Emergency Medical Services Program activities (including clinical or laboratory activities).

I agree to abide by rules and policies set forth by the EMS program, the Alabama Department of Public Health, and my clinical affiliates that I visit during the course of my studies. I realize that I have access to and a personal obligation to become aware of these rules.

I have also been advised and hereby indicate my understanding that EMS Program policy requires a 75% or better average in all coursework in any primary Emergency Medical Services course, and that a score of 75% is required in all courses to successfully continue to the next semester or complete the specified EMS Program of study.

I have received and carefully read the Background Check and Drug Screen policies of Northwest Shoals Community College Health Studies Division and fully understand their contents. I understand that healthcare program or course to which I am or will be admitted/enrolled requires a background check and drug screen to comply with clinical affiliate contracts. By signing this document, I am indicating that I have read and understand Northwest Shoals Community College Health Studies Division’s policy and procedure for background checks and drug screens. I have been afforded the opportunity to ask questions regarding this policy. I have received answers to all of my questions. I understand that this policy is in effect and may be revised at any given point and that new, existing, and re-admitted students will be required to undergo a background check and a drug screen prior to assignment to any student clinical rotation and additionally as indicated by the program of study.


I voluntarily and freely agree to the requirement to submit to a Background Check and Drug Screen and to provide an acceptable Background Check and negative Drug Screen prior to participation in clinical learning experiences. I further understand that my continued participation in the healthcare program is conditioned upon satisfaction of the requirement of the Background Check and Drug Screen with the vendor designated by the College. I further understand that if I have Background Check that renders me ineligible or a confirmed positive Drug Screen, and I am denied access to clinical learning experiences at the clinical affiliate(s), that I will be dismissed from the program. A grade of “F” will be recorded for the course(s) if I do not officially withdraw.


A copy of this signed and dated document will constitute my consent for release of the original results of my Background Check and Drug Screen to the College. I direct that the vendor(s) hereby release the results to the College. A copy of this signed and dated document will constitute my consent for the College to release the results of my Background Check and Drug Screen to the clinical affiliate(s)’ specifically designated person(s). I direct the College to hereby release the results to the respective clinical affiliate(s).


I agree to hold harmless the College and its officers, agents, and employees from or against any harm, claim, suit, or cause of action, which may occur as a direct or indirect result of the background check, drug screen, or release of the results to the College and/or the clinical affiliates.


I understand that should any legal action be taken as a result of the Background Check or Drug Screen that confidentiality can no longer be maintained.


I agree to abide by the aforementioned policy. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone. I hereby authorize the College’s contracted agent(s) to procure a Background Check and Drug Screen on me at my expense. I further understand this signed consent hereby authorizes the College’s contracted agents to conduct necessary and/or periodic Background Checks and Drug Screens as required by the clinical affiliates or program of study.

1. I understand that falsification and/or omission of information on the college and/or EMS application shall be grounds for dismissal from the program in accordance with college procedures.

2. Northwest Shoals Community College Policy: Due to the length and subject matter of each class, it is of the utmost importance that I attend all classes. Make-up examinations will be administered according to the course syllabus. I understand that failure to comply with the above attendance requirements may result in a failing grade based on academic performance.
3. I understand that I must have on file a completed health form, liability release, and current required CPR training card, dates of Hepatitis B vaccine or Waiver of Liability, and must purchase malpractice insurance.

4. In the clinical portion of the EMS Program, I understand that I must attend my scheduled clinical rotations according to the program’s clinical rules and regulations. Failure to comply fully with these will result in my receiving a lower grade or being ineligible to complete my clinical training due to my non-compliance. I agree to fully read and know the Program’s Clinical Practice Policies and Procedures outlined in my student handbook before entering any clinical area.

5. I understand that I must make a minimum of 75% in each Emergency Medical Services course in which I am enrolled to successfully complete the class and progress to the next semester.

6. I understand that I am required to abide by the rules and regulations of the clinical agency in which the clinical component of each course is performed. Failure to do so will result in dismissal from the program and a grade of “F” for the course assigned in accordance with College procedures.

7. I understand that the clinical agency with which the program is affiliated has the right to request that a student be removed from their facility, as well as the right to refuse a student admission to their facility for clinical education.

8. I understand that evaluation materials, i.e., clinical evaluations with instructor notations and counseling forms will be maintained in my student folder. I understand that upon my request, I will be permitted within 7 business days to see any information that is retained in my student folder.

9. A clinical course overall unsatisfactory will constitute failure of the entire course regardless of didactic average.

10. Due to the nature of the training received in the EMS Program, I understand that there are risks in demonstrating or receiving return demonstration in practical application of skills in the classroom and laboratory setting. I also understand that there are certain risks involved in completing clinical rotations with clinical affiliates of the EMS Program at Northwest Shoals Community College. I fully understand that I am not required to involve myself in any activity that would be potentially dangerous to me. I recognize that the EMS Program highly recommends that I carry health/hospitalization and accident insurance while enrolled in the program. I will not hold Northwest Shoals Community College, any of its employees, or other EMS student, any clinical preceptor, or any EMS Program Clinical Affiliate responsible for any injury occurred as a result of 1) any classroom/laboratory practical application or 2)performing clinical rotations.

11. I understand that during my Emergency Medical Services education that I will come in contact with infectious diseases and will be handling blood and body fluids. I further understand that my health and accident insurance and/or expenses are my responsibility.

12. I understand that I am responsible for transportation, meals, health care expenses and any liability incurred during and while traveling to and/or from education experiences.

13. The application for licensure as an EMS Professional in the state of Alabama will have questions which ask, “Have you ever been convicted of a felony or criminal offense?” and “Have you ever been arrested or convicted for driving under the influence of alcohol/drugs?” The application may be denied on the basis of this review.

14. I certify that I am not addicted to any intoxicating liquors or drugs and that I am not currently charged with or have ever been convicted of a criminal offense, other than a minor traffic violation.

15. I certify that I am of good moral character and that I have no known physical or mental difficulties that would prevent me from completing this training program. I understand that I must have a physical examination completed by a licensed physician or CRNP and have him/her complete the physical examination form required by the program before any clinical rotations are scheduled. In addition, I realize that if my physical exam does not meet with the approval of the EMS Program Medical Director or EMS Program Director, I may be required to withdraw from the program.

16. I understand that failure to comply with legal, moral, and legislative standards which determine unacceptable behavior of the EMS Professional and/or behavior which may be cause for denial of license to practice as a licensed EMS Professional constitute grounds for dismissal from the program, regardless of course standing. A grade of “F” will be assigned for any EMS course from which the student is dismissed for unacceptable behavior.

17. I understand that these rules above apply to me on any EMS course I should take in the Emergency Medical Services Program through Northwest Shoals Community College, at present or in the future.

18. I understand that it is my responsibility to read the College Catalog, EMS Program Student Handbook, each course syllabus, clinical evaluation forms and other materials that are provided to the class which outlines my responsibilities as an EMS student. I understand that failure to abide by these published materials will be grounds for dismissal from the program.

Prospective EMS students should be aware that they must comply with specific licensure requirements set forth by the National Registry of Emergency Medical Technicians and the Alabama Department of Public Health Office of EMS and Trauma, to become licensed as an EMS Professional. Things which may affect your licensure compliance include:

1.Not being 18 year of age or older.

2.Having been convicted of any criminal act, including DUI convictions.

3.Being addicted to the use of intoxicating liquors or controlled substances in the present or past.

4.Not possessing 180 degrees peripheral vision capacity or a valid driver’s license.

If you have any concerns regarding any of these items listed above, please address them to the Alabama Department of Public Health, EMS Division at 1-334-206-5383 and/or the National Registry of EMTs at 614-888-4484. Alabama EMS License requirements may be found at https://www.alabamapublichealth.gov/ems/assets/emsp.licensure.requirements.pdf

Please review the Americans with Disabilities Act as it applies to National Registry for EMTs accommodations, job demands, and worker characteristics. This explanation can be found in the National Registry brochure under Examination Accommodations or online at www.nremt.org.

The Northwest Shoals Community College EMS Program is nationally accredited by the Commission of Accreditation of Allied Health Education Programs (CAAHEP) upon recommendation of the Committee of Accreditation of Educational Programs for the EMS Professions (CoAEMSP).

Commission on Accreditation of Allied Health Education Programs 727-210-2350
www.caahep.org

To contact CoAEMSP: 214-703-8445
www.coaemsp.org

Admission to the Northwest Shoals Community College EMS Program is competitive, and the number of students is limited by the number of faculty and clinical facilities available. Meeting all minimal requirements does not guarantee acceptance. Preference will be given to graduates of Northwest Shoals Community College. Applicants will be notified in writing by the EMS office of acceptance into the EMS program. The College reserves the right to adjust requirements or use additional criteria to determine admission.

The field of emergency medical services strives to deliver up-to-date, evidence-based medicine. Since the field of medicine changes daily with new advancements, treatments, and research, the EMS curriculum is revised as needed to meet this challenge. Students will be made aware of any changes to existing curriculum or any proposed changes to the curriculum, including admission criteria, the progression guidelines, and requirements implemented by the state EMS authority, the Alabama Community College System, or National Registry of EMTs.