Application For Admission To Als Program

Virginia Beach Newport News Hampton Portsmouth Other: Specify ___________

Application Date: ______________________

Only Intermediate Critical Care

Day Program Night Program

Tidewater Community College Emergency Medical Technology Application for ALS EMS Programs

Semester: ____________________________

Paramedic Accelerated I99 PM Both only EMT-Enhanced (must have proof of EMS agency sponsorship)

Last Name: _________________________ First Name: ________________________ SSN: ______________________

Mailing Address:___________________________________________________________________________________

Contact Information

Home: ____________________ Work: _____________________ Pager: ____________________ Cell: ____________________

Fax: ________________ E-Mail: __________________________

Sponsoring Agency if Applicable: ___________________________________________________ Contact Person: ___________________________ Phone #: __________________________

Due prior to or on first day of class: (accelerated programs send with application to secure seat) TCC admission application (available at www.tcc.edu) Copy of current EMT card Copy of CPR (Professional Rescuer or Healthcare Provider) Proof of High School Graduation or GED Equivalent Copy of Driver=s License or other proof of age over 18 years

EMP # ________________ (student ID number)

Due before starting clinical / field: (accelerated programs due 1st day of class) Current physical exam to include a respiratory physical (done within last 2 years) available at http://www.tcc.edu/academics/divisions/healthprofessions/ems/physical.pdf Current PPD (tuberculin) skin test (within last 8 months) Proof of Varicella (chickenpox) immunity (by lab results or proof of vaccine) Proof of MMR (measles, mumps, rubella) vaccine since 1980 or proof of immunity Proof of tetanus toxoid vaccine within 10 years or proof of waiver Recommended: Hepatitis B vaccine series (bring verification) Criminal, sex offender, crimes against minors background check

Send requirements to:

Tidewater Community College Emergency Medical Technology Attention: Lorna Ramsey 1700 College Crescent Virginia Beach, VA 23453

757 822-7335 Fax: 822-7557 [email protected]