EMT STUDENT STATEMENT OF COMMITMENT
Please Print Using Black or Blue Ink. Your Initials on Each Page, in the Space Provided, ARE REQUIRED! I, ________________ __________________ understand that I will not receive a passing First
Last
grade, nor will I receive my EMT certificate, nor a course completion certificate if I fail to complete any of the requirements listed below: 1.
2.
3.
4. 5.
Prerequisites: I will show proof of completing the course prerequisites by the specified due date. If I present evidence that the college prerequisite challenge form has been approved, I understand that my instructor may authorize an extension. CPR Training: I will provide a copy (front and back on one side of one white 81/2” x 11” sheet of paper) of my current CPR card by the specified due date. My CPR card may be either the AHA-Health Care Provider or the ARC-CPR for Rescuers. I understand that other sources of adequate CPR training must be separately verified by my instructor and potentially may not meet the needs of the program and therefore will be denied. If my CPR class is in progress to meet this requirement, then I will submit proof of enrollment and date of completion to my instructor at which time my instructor may grant an extension. Immunizations and TB Testing: I will submit proof of two Measles/Mumps/Rubella (MMR) immunizations in my lifetime, and a negative TB test within the last 6 months. I will submit this proof by the specified due date. I understand that this proof must be in the form of an official immunization record or equivalent and must bear a physician’s or RN signature to be considered valid. Course Fees: I agree to pay all tuition and course fees and to show proof of payment of these fees by the by the specified due date. Clinical Experience: I will submit proof of attending at least 16 hours of clinical experience divided evenly between hospital and ambulance. I understand that the clinical experience verification form and patient contact log must be completed by me, signed by hospital and ambulance staff and submitted by the specified due date.
____________ Student Initials
1 of 4 Rev: 8/2004