Transcription
Great Lakes EMS Academy/Davenport University Consortium2021 Registration PackagePlease check which course you are registering for:EMT Courses in 2021 February to June Tuesday and Thursday 12:30pm – 4:30pmFebruary to June Tuesday and Thursday 6:00pm – 10:00pmJune to August Tuesday and Thursday 10:00am – 6:00pmSeptember to January Tuesday and Thursday 12:30pm - 4:30pmSeptember to January Tuesday and Thursday 6:00pm - 10:00pmAEMT/Specialist 2021 (Students must sign up for AEMT andParamedic course separately) September 2021 to December 2021, Monday and Wednesday 12:30am – 4:30pmSeptember 2021 to December 2021, Monday and Wednesday, 6:00 - 10:00pmParamedic Courses in 2021 January 2022 to January 2023 (followed by 3 month internship) Monday and Wednesday 12:30pm –4:30pmJanuary 2022 to January 2023 (followed by 3 month internship) Monday and Wednesday 6:00pm -10:00pmTo complete the form below simply tab from one box to the next. you can print the document and mail it in to us with theregistration fee via the US Postal Service, bring it in when you have your admission interview with the Director ofOperations, or save it as a file and attach to an email to the Academy, at melissa@greatlakesems.com To schedule youradmissions interview you can call the Academy at (616) 459-1736.Student Information:Last NameFirst NameStreet AddressHome PhoneCityStateE mailDate of Birth (mm /dd/yyyy)Social Security Number (last 4)Place of workStreet Address (work)Work PhoneCityFirefighter, public safety or militaryPlease describe:YesStateZipZipNoPrevious EMS Licensure? Please List:CPR certification?YesCPR Expiration date (mm /dd/yyyy)NoFOR OFFICE USE ONLY Registration Fee Paid Date Initials Tuition Payment Plan - Payment plan:
Great Lakes EMS Academy/Davenport University Consortium2021 Registration PackageImmunizationsThis is the most important document within the application package. All students must have proof of the immunizations orscreenings listed below. You may see your personal physician for this task or visit your local health department. The cost isvery reasonable at the health department. If you have any questions, please call the Academy. Affix the proof (copies) tothis document and mail it in with your application or bring it with you on the first day of class. ALL IMMUNIZATIONSARE DUE BY THE THIRD CLASS SESSION1.2.3.4.5.6.Hepatitis BT.B. screening within 12 monthsMMRTetanus booster within 10 yearsVaricella, or proof of having chicken pox (Medical Professionals note)Flu-shot (yearly) or waiver from doctor stating you are unable to receive the immunization1.InitialsBy placing your initials to left of this statement you understand that the clinical obligation for allEMS courses offered require certain immunizations and screenings that are common to thehealth care industry and are listed above. Proof of these immunizations are to be supplied to theAcademy BY THE 3RD CLASS SESSION. Failure to obtain and provide the proof ofimmunizations/screening by the 3rd class session will result in a failure of the course due to aninability to be successful in the clinical program.DisabilitiesAre you diagnosed with a disability that would affect your performance during class or clinical?YESNO If Yes, give primary diagnosis:Please explain how the disability will affect you in the classroom and clinical environment. Provide suggestions onhow the Academy would be able to reasonably accommodate the disability. Forward ALL appropriate documentationfrom your physician with a diagnosis and supporting evaluation records.Financial CommitmentInitials1. By placing your initials to left of this statement you understand that when signing up for coursesat the Academy you will be held financially responsible for the tuition for the course. That maybe done with financing through a promissory note, a loan from a bank, grants from thegovernment, or several other ways. Signing up for class and then quitting (for any reason)deprives others from the chance of getting into the course.YOU ARE RESPONSIBLE FOR PAYING THE TUITION FOR THE COURSEStudent’s SignatureDate
Great Lakes EMS Academy/Davenport University Consortium2021 Registration PackageEnrollment Contract / AgreementThe undersigned has made application to the Great Lakes EMS Academy/Davenport Consortium (hereafter referred to as TheAcademy) for admission to its EMS training program, and as part of the individual’s application for such training, theapplicant represents the following to be true.Please read carefully and initial next to each statement in the space provided:1. I understand that the EMS training program meets the Michigan Department of Community Health(MDCH), EMS and Trauma Section curriculum requirements for EMS training. Upon successfulInitialscompletion of this course I will be eligible to take the National Registry exam. It is possible for me topass the EMS training program and then fail the National Registry exam. The Academy makes noguarantee that I will pass the National Registry.1.To benefit from this training, the school requires that you must be able to read, write and comprehend theEnglish language, do basic arithmetic problems, and possess a high school diploma or general equivalencydiploma (GED).1.I agree that my completion of the EMS training program shall be contingent upon my meeting therequirements of the course of instruction which is set forth in the syllabus or as affirmed by the staff of theAcademy.1.I agree that I may be dismissed from The Academy in accordance with the policies set forth in the catalogand student syllabus. Unexcused absences, excessive tardiness, and lack of progress in training will alsobe grounds for dismissal.1.I understand that I must voluntarily submit to a drug or sobriety test anytime the school requests me to doso while attending. All costs for such testing will be paid by me. If such tests are positive, I will bedismissed from the Academy. I will not hold the school, its representatives and officials, or any otherpersons or entities including doctors of testing labs, harmless as a result of any testing results by them andwill abide by such test results and findings.1.That in performance of my functions in the EMS training program, I am not an agent or employee of TheAcademy or any of the clinical sites that I may visit while a student at the Academy. Students may not be“on the clock” if participating in clinicals at their place of employment.1.I understand that it is not possible for The Academy to guarantee employment. The school assistsgraduates, by making their names and qualifications available to companies that upon request havecontacted the school. Should you seek employment in Emergency Medical Services, your driving recordsand criminal record, if you have one, will be validated through the proper authorities. You may find itimpossible in the future to obtain a job in this industry if you have a poor driving record, pooremployment history or a criminal record.1.I understand the points mentioned in this agreement and the catalog are not all inclusive and may be addedto or changed at the discretion of the President of the Academy, if such changes or additions are deemednecessary to improve the program.1.The tuition and fees paid by the applicant shall be refunded if the applicant is rejected by the school beforeenrollment. An application fee of not more than 25.00 may be retained by the school if the application isdenied. All tuition and fees paid by the applicant shall be refunded if requested within 3 business daysafter signing a contract with the school. All refunds shall be returned within 30 days. Once the 3 businessdays have elapsed the following refund policy will apply: If a student withdraws from class between thetime they register for class and before the 3 rd class session, they will be refunded all but the deposit paid tothe Academy ( 250 EMT/AEMT, 500 Paramedic). If a student withdraws from class after the 3rdclass session, the student will forfeit all money paid to or owed to the Academy for the class that thestudent registered for and participated sInitialsInitials
Great Lakes EMS Academy/Davenport University Consortium2021 Registration PackageEnrollment Contract / Agreement (continued)The undersigned has made application to the Great Lakes EMS Academy/Davenport Consortium (hereafter referred to as TheAcademy) for admission to its EMS training program, and as part of the individual’s application for such training, theapplicant represents the following to be true.Please read carefully and initial next to each statement in the space provided:1.If The Academy ceases to conduct business for any reason they will reimburse all of the students anymonies paid towards tuition no matter of the student’s status in the class or the length of time until theend of the course.1.If a prospective student wishes to drop class after the registration fee has been paid, they must do so 30days prior to the first day of class in order to be reimbursed all monies paid to the Academy. If a studentdrops class within 30 days before class starts, they will receive all monies paid excluding theRegistration fee.1.That this instrument shall become a part of my student record for the EMS training program and it is abinding agreement between me and The Academy1.It is important that you understand that if you sign for a loan to pay for the tuition that you areresponsible for that balance no matter what happens in class. If you quit or fail the course you will stillhave to pay the loan off.InitialsInitialsInitialsInitialsStudent’s SignatureDate
Great Lakes EMS Academy/Davenport University Consortium2021 Registration PackageEMS Student Hold-Harmless, Agreement for Clinical ExposureThe undersigned, being 18 years of age or older, does hereby request permission of The Academy to participate inclinical exposures at various clinical facilities, ambulance services and hospitals. The purpose of this requestwould be solely for educational benefit. I hereby agree to abide by all clinical rules and regulations set forth byThe Academy and the respective places of business.I fully realize and appreciate the basic nature of pre-hospital and emergency medical work. I am also fully awareof the possibility that situations will arise which might result in the danger of physical harm or injury, includingbut not limited to, motor vehicle accidents, assaults, blood and body fluid exposure, and needle pokes formsyringes. I do, nevertheless, freely and voluntarily accept these risks. I further agree to keep confidential anyinformation related to patient care that I may observe. I have read, do understand, and will abide by the rulesgoverning clinical observers.If I am injured or have a communicable disease exposure while attending a clinical with any of the contractedclinical sites, I will use my personal health insurance or pay myself, all medical expenses associated with theinjury or exposure.Wherefore, in consideration of the above conditions and the granting of the above request, I hereby agree to holdThe Academy and all of other agents and assigns thereof, harmless from any and all liabilities to me for personalinjury or property damage as stated in the contractual agreement whether proximate or remote, sustained duringthe period of time that I am in the capacity of an EMS student.Student’s SignatureDate
Great Lakes EMS Academy/Davenport University Consortium2021 Registration PackageClinical Program AgreementAll participants must attend a certain number of hours in a clinical setting. The importance of experiential learning cannot beoverstated. During the clinical exposure, it is expected that all students will conduct themselves in a professional way andshow enthusiasm towards learning. Patient confidentiality must always be maintained. Proper respect for preceptors will always be conveyed. Participants will be expected to follow applicable workplace rules.Students will be required to sign up for all their clinical obligations early in the course. Throughout the course there may beoccasions when the student will need to change the schedule, this will be done by contacting the Clinical Coordinator orDirector of the Academy at the earliest possible time.All clinical’s will be scheduled through the Academy. If students sign up for clinical’s outside of the “system” used toschedule clinical’s, the time spent at those clinical’s will not count towards their clinical obligations. If a student has anemergency cancellation of a clinical, they should call the Director at the earliest possible time to advise her that they will notbe able to make their clinical obligation.1.InitialsBy initialing to the left you understand that there is a clinical obligation for the course that isfurther explained in the catalog and student manual. Scheduling clinical can be challengingfor some students due to other commitments. All clinical scheduling will be done through theClinical Coordinator or Director of The Academy.The students at the Academy wear a clinical uniform to all clinical’s and to some of the classroom sessions. The Academyhas earned a reputation for providing well-prepared and professional prehospital care providers. To maintain this reputation,the students must present themselves in a highly professional manner while in the public’s eye and wearing the clinicaluniform.Uniforms items that students may be required to purchase include:Dark blue working pants: These can be any brand. The student should consider purchasing the pants from a company thatsells uniforms to EMS workers. These pants should be well fitted to the student. No holes or frayed edges. Nye Uniformhas a good pant with cargo pockets that many of the students will buy.Navy uniform shirt: The uniform shirt can be long or short sleeved. The shirt will be purchased at Nye Uniform. This shirtshould be clean, well-fitted to the student, and free of wrinkles when worn in public.Black boots: Students are encouraged to purchase and wear black working boots for use in the ALS ambulance clinical’s.These boots are the standard footwear for people working in EMS. Students can wear a black shoe. If black shoes are worn,the student will wear dark socks. The shoe will be all black. If the shoe or boot has laces, the laces will be black. Mostrunning shoes and tennis shoes are not appropriate.Uniform belt: The uniform will be worn with a belt. The belt will be black or dark blue. Students should use a belt that istypically used in EMS.T-shirt: Students should wear a T-shirt with the uniform. This t-shirt will be white or navy and will be free of any writing orgraphics that can be seen through the uniform shirt.
Great Lakes EMS Academy/Davenport University Consortium2021 Registration PackageClinical Program Agreement1.I understand that the clinical aspect of the program is an essential part of the EMS training. Tosuccessfully complete the course, I must follow the rules described for clinical exposure andcomplete the prescribed hours.1.I understand that while I am in the clinical environment, I represent the EMS profession and theAcademy, as well as myself. I will conduct myself in a professional manner and follow therules governing apparel and personal appearance.1.Haircuts/Hairstyles: Student’s hair must be neat, clean, and secured away from the face. Malestudent’s hair will be no longer than shoulder length. No Mohawks or bright/unnatural lookinghair color (blue, purple, etc.).1.Hygiene: Students will practice good personal hygiene habits throughout the course.1.Facial Hair: Mustaches will be neat, clean, and kept off the upper lip. No other facial hair willbe authorized. No beards, no goatees, no long sideburns.1.Drugs and Alcohol: Students will not drink any alcohol for 8 hours prior to attending aclinical. The use of any illegal drugs is forbidden at any time during the course.1.Fingernails: Nails will be short and clean. Clear nail polish is preferred. No brightly colorednail polish. Acrylic nails are prohibited.1.Jewelry: Only two stud type earrings (one in each earlobe) are allowed during clinicals. If youare going to wear an earring, you need to wear two earrings. No other visual piercing will beauthorized. Nothing will be worn on the eyebrows, tongue, lip, cheek, nose, or around theexterior aspect of the ear.1.Clinical uniforms are not to be worn when going to a bar or purchasing alcohol. The studentcan just take the uniform shirt off to go into an establishment that serves alcohol. You need topay attention to what you are doing while in uniform. You are representing our industry.1.While wearing the uniform, the student will adhere to all the uniform regulations. That wouldinclude the rules regarding facial hair, jewelry, hygiene, and tattoos.1.Students should get used to the proper care and handling of uniform shirts. This would includeironing the uniform. Professionalism begins with an appearance of professionalism. The firstimpression that you make with your patients and your patient’s family can be vital.1.If a student is injured or has a communicable disease exposure while attending a clinical withany of the contracted clinical sites, the student will use their personal health insurance or paythemselves, all medical expenses associated with the injury or tialsStudent’s SignatureDate
Great Lakes EMS Academy/Davenport University Consortium 2021 Registration Package Please check which course you are registering for: EMT Courses in 2021 February to June Tuesday and Thursday 12:30pm - 4:30pm February to June Tuesday and Thursday 6:00pm - 10:00pm June to August Tuesday and Thursday 10:00am - 6:00pm
