EMT Basic Program (EMT 104) Check List The following requirements must be acknowledged at the time of registration. _____ Be at least 18 yrs of age when acknowledging this form. _____ Provide a photo copy of reading competency of one of the following: • ASSET 36 or above • COMPASS 70 or above • NELSON DENNEY 9.0 or above • ACCUPLACER 62 or above • AIMS reading score of 708 or above • CRE 081 with a grade of C or above • Associate/Bachelor/Master degree from an accredited college _____ Register for EMT101 (CPR) or provide a copy of your current CPR card at Healthcare Provider level or Professional Rescuer level. A copy of a valid CPR card must be provided on or before 1st day of EMT104 class. CPR must be good through the duration of the EMT course. _____ Physical exam and immunization forms (with copies attached) must be completed and turned in to the EMT/FSC Department on or before 1st day of EMT104 class. The physical form AND TB test (with negative results) cannot be older than 6 months. Incomplete forms will not be accepted. _____ You must bring all required paperwork to the EMT/FSC Department on or before the 1st day of EMT104 class. Missing or incomplete documents constitutes an automatic withdraw from the course with a 100% refund. The cost of Drug screens and fingerprint clearance cards cannot be refunded. Clinical Requirements ____ Prior to clinical assignments, each student must obtain a DPS Fingerprint clearance card. The average cost could range from $69.00 - $89.00. Be prepared, this process could take 6 weeks or longer. Valid/current Concealed Weapons Permits OR a Commercial Drivers License will be accepted. If a student is unable to meet this requirement, a grade of “INC” will be given, until the student can provide proof of this requirement. No other background checks will be accepted. _____ On the first day of class, students will be provided a drug screen permission form that must be provided to Sonora at the time of drug testing. The average cost is $35.00. Drug screens must have a “NEGATIVE” result within 30 calendar days from the start of class. Students who do not meet this requirement will be withdrawn from the course with no refund. _____ During your EMT104 class you must complete 8hrs of a clinical rotation, to include five (5) patient assessments and receive a satisfactory evaluation. Incomplete forms will not be accepted. _____ If any of these requirements are not met accordingly, the student will be given an “Incomplete” grade and or withdrawn from the course. Students who are eligible for an “INC” grade must return within 6 months of EMT104 class ending, to complete their clinical requirements. If a “PASSING” five panel drug screen is not provided on day two of EMT104, the student will be withdrawn with a 100% refund. Course Requirements _____ During your EMT104 class you must successfully complete practical skills testing with a minimum score of 80%, complete the final exam with a 75% or above. A cumulative score of 75% or above must be maintained throughout the course. _____ During your EMT104 class you must attend each scheduled class day. Two or more absences may result in the student being withdrawn with no credit and no refund. Any absence should be reported immediately to your instructor or call 602-285- 7207. _____ Have all required textbooks and materials for your scheduled courses (EMT101, EMT104).By signing below, I understand that my physical exam and the immunizations form (copies attached) will be completed and returned to the EMT104 Department on or before the 1st day of my EMT104 class or I will be withdrawn from the course with a 100% refund. I also understand that I must provide a copy of my CPR card (good through the duration of EMT104) at the appropriate level on or before the 1st day of class, or I will be withdrawn from the course with a 100% refund. In addition, I understand that I must provide a current DPS issued fingerprint clearance card, OR a valid/current Concealed Weapons Permit OR a current Commercial Drivers License PRIOR to being scheduled for a clinical assignment. I understand if I do not meet this requirement, I will receive an “INC” for the course and may be ineligible for certification. I understand that I must provide proof of a “PASSING” five (5) panel drug screen within 30 calendar days from the start of class . If I cannot meet this requirement, I will be withdrawn from the course with no refund. __________________________________________ _________________ STUDENT NAME (Print) DATE __________________________________________ _________________ STUDENT SIGNATURE DATE __________________________________________ _________________ EMT STAFF or ADVISOR NAME (Print) DATE __________________________________________ PROSPECTIVE EMT104 INSTRUCTOR STUDENT COPY Rev