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Public Safety Training Facility

Monroe Community College
Rochester, New York


PARAMEDIC PROGRAM SUPPLEMENTAL INFORMATION FORM

(Students MUST also matriculate into EM01 at the MCC Brighton Campus to be

eligible for the degree and financial aid)



PUBLIC  SAFETY  TRAINING  FACILITY
Paramedic Education
Suite 216
Rochester, New York 14624





INSTRUCTIONS: Print or type all information in the spaces provided. 
Attach additional sheets as needed.  Failure to complete the form or
submit the required documentation may result in a rejection from the program.
Return completed package to the Selection Committee at the address listed above.


Student Information:  (Print or type)



Name:_________________________________________________________________
	(Last)	                 (First)                      (M.I.)

Address:______________________________________________________________


City:____________________ State:________ZIP:______________ County:____


Day Telephone:     (______) _______ - ______________

Evening Telephone: (______) _______ - ______________

Pager Telephone:   (______) _______ - ______________  Voice  Numeric  


EMT No: ________________ Level: [ ]B [ ]I  [ ]CC  Expiration Date:_________

Date of Birth:____/____/____(You must be at least 18 years old)	

Original Certification Date:_______________ Instructor Name________________






Education:


        Institution       Location      Type of Degree/Cedit    Dates

H.S.______________________________________________________________________

College___________________________________________________________________

Other_____________________________________________________________________

Other_____________________________________________________________________



List all other EMS, medical, health, or courses/conferences/training 
(other than re-certification programs) that are applicable.

Name of Course/Conference/Training       Location      Dates Attended

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________



EMS Experience: Paid and volunteer activities. List chronologically:

Where      Job Title     Dates      Hours/Month   Supervisor & Phone #

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________





References:

List two references who are familiar with your EMS activities:

Name             Address             City            Phone Number(s)

____________________________________________________________________________

____________________________________________________________________________

Educational History:

Have you ever applied to an A-EMT-CC or Paramedic Program any where in the 
USA? [ ] No.  [ ] Yes.  If Yes, fully describe the reason(s) you did not 
complete the program and provide the CIC's name with a phone number. 



____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________






Certification Statement:

I, the undersigned, acknowledge that the information set forth in these
documents are true and accurate.  I also give permission to Monroe Community
College, the selection committee members, The Medical Director and the course 
faculty to contact the listed references and to conduct background investigations.
I understand that any information given by these References will remain 
confidential between the College and the Reference. I also understand that
false or misleading information can be grounds for dismissal from the
applicant pool or the program.


______________________________________________________________________________
Signature of Prospective Student                                Date                                                                                                     



  ATTACH THE FOLLOWING DOCUMENTS TO THIS FORM:

    [   ]  A cover Letter of introduction and of your interest.

    [   ]  A copy of your EMT card.

    [   ]  A copy of any other related EMS/Medical/License documents.

    [   ]  Two Letters of reference from individuals other than those listed above.

    [   ]  Any other material relevant to this program.


 
	
FOR OFFICE USE ONLY----------------------DO NOT WRITE BELOW THIS LINE---------


Complete?  [  ]  Yes    [  ] No____________________________________________________
 
1                                  Initial	On		Rating

2                                  Initial	On		Rating
 
3                                  Initial	On		Rating
 
Ref 1                      Ref 2                       Ref 3

Action Taken












Home After Printing Press Here to Return to Paramedic Home Page

URL: /depts/pstc/palsap.htm

Updated: October 6, 2006

MCC-B364
mcc-web01.monroecc.edu