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EMORY EMS EMR COURSE APPLICATION 2018-2019

Dear EMR Course Applicant,

Emory Emergency Medical Services (EEMS) is a professional EMS agency that provides vital medical services, education, and outreach to Emory University and the surrounding community. EEMS was founded in 1992 as the first collegiate EMS agency in the state of Georgia and is an award-winning and nationally recognized collegiate EMS organization.

In the EMR Course, students will learn life-saving patient care skills through both classroom and practical experience. The course is approximately 6 months in length; it begins in October 2018 and will conclude in March 2019. Classes will be on Tuesdays (8am-10am) and Saturdays (8am-5pm) and will be held on Emory University's main campus. See website for more details: eems.emory.edu. In addition to classroom hours, students may have the option to complete clinical hours with top EMS agencies and hospitals in the metropolitan Atlanta area.

The purpose of our EMR course is to develop a network of first responders on the campuses of Emory University. These first responders will render aid and may provide life saving care, in many cases before the arrival of higher trained EMS personnel get to the scene. While this course does require considerable work and commitment, it will be one of your most rewarding activities at Emory.

Upon successful course completion, graduates will be expected to attempt both the computer based and psychomotor portions of the NREMT EMR exam and upon passing, to volunteer for at least one year as an Emory EMS First Responder.

For more information, reference eems.emory.edu.

Thank you for your time,

The Emory EMS Command Staff

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EMORY EMS EMTR COURSE APPLICATION 2018-2019 APPLICATION must be RECEIVED by

OCTOBER 8, 2018

ALL FIELDS ARE REQUIRED. FALIURE TO SUBMIT A COMPLETED APPLICATION WITH ALL DOCUMENTS REQUESTED WILL PROHIBIT

ACCEPTANCE INTO THIS COURSE.

Instructions: Complete this application to the best of your knowledge. All fields should be typed. Print completed application and submit hard copies to the address below. Emailed and faxed applications will not be accepted. Ensure that this page (check-off sheet) is on the front of your application and initialed prior to mailing.

Send or bring completed application to: Emory EMS

Attn: 2018 EMR Course Application 1784 N. Decatur Rd., Suite G-01

Atlanta, GA 30322

Initial on the following lines in blue or black pen indicating that all essential documents are in order to process your application.

________Printed, Completed Application

________Copy of Immunization Records

________Resume/CV. Maximum 3 page resume or CV which includes any other extracurricular activities, leadership positions, volunteer work, or honors/awards you

would like to tell us about.

________Letter of Recommendation/Support from Supervisor or Department (This Letter is Highly Preferred, but Optional)

________By initialing here, I am acknowledging that I have read the “Dear EMR Course Applicant” letter (above) and understand that upon completion of the Course and testing, I will be expected to volunteer for Emory EMS for a minimum of one year.

For questions, email eems.education@emory.edu or call (404) 727-0180

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APPLICANT INFORMATION

Name FIRST MIDDLE

State Zip Code

Cell Phone ( ) -

Emory Student/Employee ID#

Social Security Number

Parent/Guardian Name (if under 18)

Permanent Address

City

Home Phone ( ) -

Emory P.O. Box

Date of Birth

Primary E-mail Address

Yes No Are you alcohol or drug dependent?

Yes No Have you ever been convicted in any court of a felony or other criminal offense, or do you have any criminal offense pending? (If yes, attach an explanation)

Fill in the blanks AND attach LEGIBLE documentation of ALL of the following: Hepatitis B (First dose required)

Dose 1 Date___________ (required) Dose 2 Date___________ Dose 3 Date___________

MMR: Measles/Mumps/Rubella (Both doses required) Dose 1 Date___________ Dose 2 Date___________

Chicken Pox (Documentation Required) Do you have a history of this disease? Yes No If Yes: Date(Month/Year) ___________ If No: Known serologic immunity? Yes No

or Vaccine received Dose 1 Date___________ Dose 2 Date___________

I do, by my signature, certify that the information in this application is true and correct to the best of my knowledge. I understand that willfully supplying false information is sufficient cause for rejection of my application or removal from the course.

Signature Date

Parent/Guardian Signature (if under 18) Date

Yes No Are you Emory University staff or faculty? If yes, what is your position/title?__________________________________________________________________If no, how are you affiliated with Emory University? List all current healthcare certifications or licenses that you have, including cert/license # & state/location:

LAST

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Please take time and care in answering the questions below. Character limits are strictly enforced.

The purpose of the EMR course is to prepare program graduates to volunteer at Emory as part of a First Responder Network.. Why do you want to be an EMR, and how will you contribute to the organization? (2500 characters)

Enter response here

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The EMR course requires a considerable amount of time in addition to your other Emory job-related tasks and duties. Describe a time in your career when you had too many things to do and you were required to prioritize your tasks. (2500 characters) Enter response here

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Describe a significant mistake that you made recently in your life. Did you resolve the situation? Explain. (2500 characters) Enter response here

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Give an example of a time in your career when you had to figure out how to get along with someone that was difficult to work with. Explain why the person was difficult to work with. How did you overcome your differences and work as a team? (2500 characters)Enter response here

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Use the following link to access the NHTSA National EMS Scope of Practice Model, and review p. 22-23, "Emergency Medical Responder": https://www.ems.gov/education/EMSScope.pdf

Considering the information contained in the Scope of Practice document, what scares you the most about becoming an EMR? When you think about what it will be like to be an EMR, what are you most looking forward to? (1500 characters)

Enter response here

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Write about something you are passionate about. (1500 characters)

Enter response here