Name
Name Relationship
Address
City
Daytime Telephone Evening Telephone
Pager / Cel
Social Security #
Have you ever previously applied for one of our paramedic programs?
Date(s):
Date of Birth
State ZIP
Address
City
Daytime Telephone Evening Telephone
Pager / Cel
State ZIP
yes
Personal Information
Emergency Contact
no
Have you ever previously applied for any SPCI courses?
Date(s):
yes no
Are you eligible for V/A benefits? yes no
Current Level of Certification
Current certification as an EMT-Basic in any state is a minimum prerequisite for this program
EMT-Basic EMT-Intermediate RI EMT-Cardiac
Other
Massachusetts # Date of Original Issue Exp. Date
Exp. Date
Exp. Date
Exp. Date
Exp. Date
Rhode Island # Date of Original Issue
National Registry # Date of Original Issue
Other State # Date of Original Issue
Licenses and Certifications (please submit photocopies of all certifications and licenses with your application)
Driver’s License # State
Page 1
Safety Program Consultants, Inc.306 Winthrop St., Taunton, MA 02780(800) 499-6428
Param
edic Class A
pplication
Other Licenses and / or Certifications
Education
Other
CPR
Name / Location Major Degree Obtained
High School
Trade School
College / University
Graduate School
How long have you been actively involved in Emergency Medical Services?
FF1 FF2 Hazmat CDL PALS ACLS
CPR / AED Instructor First Aid Instructor ETT EVOC
Date / Location / Instructor of initial EMT-Basic program:
Date / Location / Instructor of advanced level EMT program:
Essay QuestionsPlease use a separate sheet of paper to answer the following
1) Has your EMT certificate or authorization to practice ever been revoked or suspended?
Yes No
2) Have you ever been convicted of a felony in any state?
Yes No
3) Have you ever been convicted of any offense related to controlled substances?
Yes No
Yes, without reservation Yes, with some concerns Please contact me - I am not sure
If you answer “yes” to any of the following questions please explain in detail on another piece of paper
Page 2
1) What personal and professional goals have you set for yourself, and what have you done to fulfill them?
2) In essay form, please tell us what attributes you posses that would make you a good candidate for our paramedic program.
4) Are you able to make time commitments (including reliable transportation) for the required didactic and clinical requirements which average 26-30 hours per week?
Safety Program Consultants, Inc.306 Winthrop St., Taunton, MA 02780(800) 499-6428
Param
edic Class A
pplication
Safety Program Consultants, Inc.306 Winthrop St., Taunton, MA 02780(800) 499-6428
Param
edic Class A
pplication
Name
Reference 1Title / Position
Address
City
Daytime Telephone Evening Telephone
State ZIP
Name
Reference 2Title / Position
Address
City
Daytime Telephone Evening Telephone
State ZIP
Incomplete or illegible addresses may result in rejection of application.Please list two references not related to you. Each person will be contacted by SPCI.
Page 3
Upon receipt of this application, you will need to complete a pre-test consisting of 250 multiple choice questions covering math, reading, and general EMS knowledge. Pre-tests may be scheduled through the office Monday - Thursday 9:00 am - 4:00 pm at SPCI Taunton. Please allow three hours for this exam. You will also be required to attend an interview prior to acceptance.
Cost for textbooks required for this course are not included with the tuition. Textbooks may be purchased through the school; if you wish to purchase books from the school please indicate and sign below. Students who purchase textbooks from an outside source will be required to verify the correct publishers and editions prior to the beginning of class.
Upon acceptance into the Paramedic program, you will receive information for tuition payment. If you have any questions concerning tuition and tuition payment options please contact SPCI at (800) 499-6428. SPCI accepts cash, personal checks, money orders and most major credit cards.
I wish to purchase textbooks through the school and agree to pay the cost of these textbooks
I do not wish to purchase textbooks through the school and understand that it is my responsibility to acquire the correct textbooks prior to the first day of school. I further understand that failure to obtain the required textbooks will affect my class standing up to and including removal from the program.
Signature Date
Page 4
I hereby attest and affirm that I am committed to this EMT-Paramedic Education program and will make sufficient time available for its completion. I attest that I will pay all fees and tuitions incurred by myself while enrolled in this program as specified by my financial agreement. I also attest to the fact that all information provided by me is true and correct to the best of my knowledge. Any attempt to offer incorrect or fraudulent information will result in immediate withdrawal of this application, termina-tion from the program, and forfeiture of future program acceptance.
Safety Program Consultants, Inc. does not discriminate on the basis of race, creed, color, sex, age, nationality, or sexual orientation.
Please return this application along with all essay questions, photocopies of all applicable certifications and a check or money order for seventy five($75) dollars US to:
Safety Program Consultants Paramedic Applications306 Winthrop St.Taunton, MA 02780
Please consult and review this document with your own legal counsel if you have any concerns.
Signature Date
Ethnicity (optional - for statistical purposes only)African American
Hispanic
Asian
American Indian
White
Other
Param
edic Class A
pplicationSafety Program Consultants, Inc.306 Winthrop St., Taunton, MA 02780(800) 499-6428