EMT Registration Form

Which classroom format are you interested in? Select One*
- 12-Weeks In-class Course
- 12-Weeks Hybrid Course
- Nationwide EMT Basic Course
Name*
First Middle Last
Social Security Number*
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Cell Phone
Home Phone (if any)
Would you like us to contact you by phone
- Yes
- No

1st Emergency Contact*
First Last
Relationship*
Emergency Contact Phone Number*
2nd Emergency Contact*
First Last
Relationship*
Emergency Contact Phone Number*

Name of High School*
High School Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Did you graduate?*
- YES
- NO
When did you graduate?*
MM slash DD slash YYYY

Did you attend any College or other school?*
- YES
- NO
- Not Applicable
Tell us about any other school or colleges you attend in the past or present
Name of other School or College
Address of other Schools or College
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Did you graduate?
- YES
- NO
- Not Applicable
When did you Graduate
MM slash DD slash YYYY

Have you previously made admission to this program?*
- YES
- NO
GED Certification?*
- YES
- No
High School Diploma?*
- YES
- NO
Desired Program Date*
MM slash DD slash YYYY

Have you ever been convicted of a misdemeanor, felony, DUI or DWI or do you have any charges pending?*
If yes, please attach a separate page giving a brief description of the incident. Include dates and penalties assessed.
Max. file size: 100 MB.

Click here to upload a color copy of your US Government-issued photo ID.*
Max. file size: 100 MB.
Acceptable documents include Driver’s Licenses, State ID Cards, USA issued Passports and other Federal or State issued photo ID cards.
Upload Copy of High School Document*
Max. file size: 100 MB.
Acceptable documents include US High School Diploma, High School transcripts (showing graduation), college transcripts which list High School name and graduation date, GED certificate, and foreign education Equivalency Evaluations showing equivalency to a US High School Diploma. We cannot accept college degrees or college transcripts that do not have the High School name and graduation year listed, or any education documents issued outside the USA.

EMT Basic Program Functional Expectations*
I agree to the EMT Basic Program Expectations
The following functional position description for the EMT, AEMT, and EMT-P is provided as a guide for advising those interested in understanding the qualifications, competencies, and tasks required for emergency medical services certification. It is the employer’s ultimate responsibility to define specific job descriptions within each Emergency Medical Services (EMS) entity.
Qualifications
An individual must complete a Texas Department of State Health Services approved course and achieve competency in each of the psychomotor skills to qualify for EMS certification or licensure. Also, the individual must achieve a passing score on the National Registry of EMT’s examination. EMS personnel must be at least 18 years of age. Generally, the knowledge and skills required show the need for a high school education or equivalent. EMS personnel must have the:
A. Ability to communicate verbally via telephone and radio equipment;
B. Ability to lift, carry and balance up to 125 pounds (250 pounds with assistance);
C. Ability to stand for long periods of time up to 8 hours at a time without resting.
D. Ability to walk long distances upwards of 2 miles.
E. Ability to interpret written, oral and diagnostic form instructions;
F. Ability to use good judgment and remain calm in high-stress situations;
G. Ability to work effectively in an environment with loud noises and flashing lights;
H. Ability to function efficiently throughout an entire work shift 8-48 hours;
I. Ability to calculate both weight and volume ratios and read small print under life-threatening time constraints;
J. Ability to read and understand English language manuals and road maps;
K. Ability to accurately discern street signs and address numbers;
L. Ability to interview patient, family members, and bystanders;
M. Ability to document, in writing, all relevant information in the prescribed format in light of legal ramifications of such; and
N. Ability to converse in English with coworkers and hospital staff as to the status of the patient.
EMS personnel should possess good physical dexterity with the ability to perform all tasks related to the highest quality patient care, which can include: having the ability to bend, stoop and crawl on uneven terrain and to withstand varied environmental conditions such as extreme heat, cold and moisture is vital, ability to work in low light, confined spaces and other dangerous environments as required. EMS personnel should also be able to complete the following tasks.
A. Receives calls from dispatchers, responds appropriately to emergency calls, reads maps, may drive the ambulance to emergency site, uses most expeditious route, and observes traffic ordinances and regulations.
B. Determines nature and extent of illness or injury, takes pulse, blood pressure, visually observes changes in skin color, auscultates breath sounds, makes the determination regarding patient status, establishes priority for emergency care, renders appropriate emergency care (based on competency level); may administer intravenous drugs or fluid replacement as directed by the physician.
C. May use equipment (based on competency level) such as, but not limited to, defibrillator, electrocardiograph, performs endotracheal intubation to open airway and ventilate patient, inflates pneumatic anti-shock garment to improve patient’s blood circulation or stabilize injuries.
D. Assists in lifting, carrying, and transporting patients to an ambulance and on to a medical facility.
E. Reassures patients and bystanders, avoids mishandling patient and undue haste, and searches for medical identification emblem to aid in care.
F. Extricates patient from entrapment, assesses the extent of the injury, uses prescribed techniques and appliances, radios dispatcher for additional assistance or services, provides light rescue service if required, provides additional emergency care following established protocols.
G. Complies with regulations in handling deceased, notifies authorities, and arranges for protection of property and evidence at the scene.
H. Determines appropriate facility to which patient will be transported, reports nature and extent of injuries or illness to the facility, asks for direction from hospital physician or emergency department.
I. Observes patient en route and administers care as directed by the physician or emergency department or published protocol.
J. Identifies diagnostic signs that require communication with the facility.
K. Moves the patient into the emergency facility from the ambulance.
L. Reports verbally and in writing concerning observations about the patient, patient care at the scene, patient care en route to the facility, and aids emergency department staff as required.
M. Maintains familiarity with all specialized equipment.
N. Replaces supplies, sends used supplies for sterilization, checks all equipment for future-readiness, maintains ambulance in operable condition, ensures ambulance cleanliness and orderliness of equipment and supplies, decontaminates vehicle interior, determines vehicle readiness by checking oil, gasoline, water in battery and radiator and tire pressure.

I have read and understood the above functional position description for an EMT Basic Program.
By signing this form, I certify that I can meet an Emergency Medical Technician’s functional expectations and can continue with the EMT course at Roxell EMT.

CastleBranch Account*
I agree to the CastleBranch Requirements
Roxell EMT uses CastleBranch to track all immunization, background checks, drug testing, and other trackers required for your EMT program.
Upon receiving your payment for the class. A confirmation email will be sent to me with information on how to create and uploading documents into our clinical tracker called CastleBranch.
As a student, you understand that to successfully complete your EMT program you are required to submit your immunizations and other requested documents per your Castle Branch tracker.
All documents must be submitted, and at least pending, by the beginning of the Fifth Week of class. Failure to complete may result in termination from the EMT Basic Program.
There will be no refund for termination from the program due to an incomplete castle branch tracker.
If termination does not occur; understand that receiving clinical hours is not guaranteed once the clinical start date is passed due to clinical site availability.
Below is the list of Immunizations and Documents required prior to attending clinical rotations
We strongly recommend getting these taken care of immediately, as waiting until the last minute can cause a delay in starting your clinical internship.
Requirements:
• MMR – Measles (Rubeola), Mumps, & Rubella: Proof of two MMR’s
• Varicella (Chicken Pox): Proof of two vaccinations at any time of the disease
• Hepatitis B: Be in the process of completing (or have completed) the hepatitis-B vaccination three-shot series)
• TB (Tuberculosis) Negative test within six months of the class start date
• Tdap (Tetanus, Diphtheria & Pertussis): Proof of vaccination within last 10 years)
• Flu (Influenza) required during the current Flu Season
• In addition to your immunizations, you will also need to submit a Physical Examination form from your Doctor.
The document’s requested will be uploaded and submitted for approval to your Castle Branch account. After registration, you will receive an email with additional information on how to purchase and access your CB tracker.
Activating your tracker will also cover the required background check and drug screening.

EMT Basic Course Payment Policy*
I agree to the EMT Basic Course Payment Policy
There are three payment options available for the EMT course:

Option 1: Pay in full $1499

Option 2: Pay $800 down. Three weekly payments of $283. $150 Install fee included

Option 3: Pay $500 down. Seven weekly payments of 209. $250 install fee included
How do you plan to pay for the course? Select ONLY option*
- Tier 1 : Pay in Full
- Tier 2 Installment: $800 down and three weekly payment of $283
- Tier 3 Installment: $500 down and six weekly payment of $209
By selecting your preferred payment plan below, you agree to have all payments automatically debited from the credit/debit card on file starting week one of class.

Electronic Signature – PRINTED NAME*

I understand that falsifying any records pertinent to this application can lead to ineligibility or immediate dismissal from the program. My signature below attests that the information contained on this application is true and accurate to the best of my knowledge. I certify that the PRINTED NAME below is my ELECTRONIC SIGNATURE.
Todays Date*
MM slash DD slash YYYY
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EMT Registration Form

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