Paramedic Program Application

Admissions is granted without regard to race, creed, disability, color, religion, sex, sexual orientation, age, national origin, marital status, gender identity or gender expression, status with regard to public assistance, or inclusion of any group or class protected by state or federal law. Inver Hills is committed to compliance with Title VI, Title IX, Section 504, the Americans with Disabilities Act, and all state statutes and regulations regarding to removing barriers to equal employment and educational opportunity. This document is available in an alternate format by calling 651-450-3508 or TTY/Minnesota Relay at 1-800-627-3529.

Fields marked with an asterisk "*" are required.

Student Information
First Name:*
Last Name:*
Middle Name:
Tech ID (if you have one):
Birthdate (mm/dd/yyyy) :*
Street Address:*
City, State, Zip:*	,
Email:*
Phone Number:*
Alt. Phone:

Schools Attended List each College or Post‐Secondary School Attended and Degree or Certificate Earned Request an official transcript from each institution be sent directly to Enrollment Services at IHCC if not previously done

Emergency Medical Services Certifications

Do you have a current National Registry EMT Certification?

Yes No

Do you have a current Minnesota EMT Certification?

Yes No

I have never been certified and I am interested in becoming an EMS Provider.

Patient Care work and volunteer history

List any place that you worked, including start date, end date, city and state.

Employer/Agency	Nature of Work	Start Date (MM/YY)	End Date (MM/YY)	City/State	# Year (Full Time Equivalent)

Documents

In order to be considered all documents related to EMS.

I have requested all official transcripts be set directly to Inver Hills enrollment services from each of the colleges, universities, or other post-secondary programs I have previously attended. If transcripts have previously been submitted to Inver Hills, I do not need to send again.

Yes No Inver Is the only college I attended

Prerequisites

Course Number	Course Name	Petitioned for Exemption
EMS 1122	EMS Systems	Yes No
EMS 1130	Advanced EMT	Yes No
EMS 1188	AEMT Pt. Care Experience	Yes No

Are you now serving, or have you served, in the United States Armed Forces? Yes No
Are you currently a participant in a Dislocated Worker Program? Yes No
Are you fluent in a language other than English? Yes No
If yes, what language(s)?
Guaranteed Employment
Do you have guaranteed employment as a paramedic once you have completed the paramedic program? (if you do, you will need to submit the statement of employment and return to the Program Director) Yes No
Acknowledgements: Student Conduct The Inver Hills EMS Program expects each student to conduct him/herself in accordance with all Inver Hills Community College policies, applicable laws, EMS professional behavior standards and generally accepted norms of conduct. Code of Conduct regulations apply on all campus property and at all college‐sponsored off‐campus activities including hospital and field clinicals. Behavior which violates professional standards or the Student Code of Conduct will be investigated and may result in discipline up to and including dismissal from the Paramedic Program. Internships and Clinical Experiences All students will be required to participate in ambulance internships and other patient care experiences as part of the Paramedic Core Program. Each clinical/internship site will be selected by the program director and faculty based on its ability to provide a positive learning environment and patient care opportunities. Participation in patient care experiences are a priviledge. We are guests at each of the sites. Inver Hills EMS reserves the right to assign students to patient care experience sites and to dismiss a student from such site if violation of IHCC Student Code of Conduct or EMS Student Manual policies and procedures occur. Students may be expected to participate in patient care experiences a considerable distance from the Inver Hills campus. The college will make reasonable effort to place students for internship/clinicals at their preferred location, however this is not always possible. Criminal Background Checks In compliance with the MN Dept. of Human Services (DHS) and as a required condition of clinical affiliation, DHS background studies will be conducted on all paramedic core students. In addition, students will be required to complete a background study beyond MN DHS Study. Each student will be required, as a condition for participation in the clinical experience program, to obtain background checks. The background checks include social security number validation, address history for past 10 years, a felony and misdemeanor criminal history search for the state of Minnesota and all counties outside Minnesota identified by the student’s address history for the last seven years, a national criminal history database search that includes sex offender and child/elder abuse registries, convictions, licensure sanctions, and a search of governmental agencies such as the Office of Inspector General. Students must have documentation of clearance for botht he DHS study and the other Study in order to participate in the Paramedic Program. There is a cost due at the time of initiating the additional study. Directions for completing this study will be provided to accepted applicants at the time of program orientation. Some sites also require additional criminal background check that may be conducted as well. Personal Health Due to the inherent risks involved with EMS and for the benefit of your own health, all Paramedic students are required to maintain personal health insurance for the duration of their enrollment within the program. Accepted applicants will be required to provide physician verification of good health and immunization documentation. Student Uniform All students enrolled in EMS courses at Inver Hills Community College are required to wear the approved student uniform as outlined in the EMS Department Uniform Policy during all classes, clinical experiences and department sponsored events. Driving Record Inquiry Students enrolled into the Paramedic Program will be asked to submit their driver’s license information to the college at the time of admission and if found to have an ineligible driving record (as defined by the college vehicle use policy) will not be allowed to drive college vehicles.
* By checking the box, I hereby certify that the information on this application form is complete, accurate, and true to the best of my knowledge. I have read the above listed statements and agree to adhere to all Inver Hills Community College and EMS department policies and procedures.
Date:*
Disclosure NOTE: Federal and state legislation requires that the contents of the students files be open to review by the student. Application forms, high school transcripts, test daat, letters, and recommendations that are sent as part of any application for admissions will be open to the students's review upon request.