# Emergency Medical Services (EMS) Field Experience Application for Participation

In preparation for students to register in the EMS program, specific items are needed before instructor permission to enroll in EMS110, EMS111, EMS112 and EMS113 will be granted (you must concurrently register in all four courses, unless otherwise stated by the EMS Internship Coordinator). As a clin

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[Open original PDF →](https://www.delta.edu/programs/fire-science/_documents/emergency-medical-services-application.pdf)

## Document text

SHERGENG

For ACE Office uce onlv.

PO CAL SESATO

## Emergency Medical Services (EMS) Field Experience Application for Participation

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In preparation for students to register in the EMS program, specific items are needed before instructor permission to enroll in EMS110, EMS111, EMS112 and EMS113 will be granted (you must concurrently register in all four courses, unless otherwise stated by the EMS Internship Coordinator).  As a clinical student, it is your responsibility to maintain current health records while in the EMS program. For additional program information, go to

https://sites.delta.edu/collegeinfo/Academics/Divisions/SitePages/Emergency%20Medical%20Services%20(EMS).aspx.

For approval to enroll in the EMS courses and participate in a field experience, and before reporting to the field site, students must have the following on file in the ACE Office, A003 (West Courtyard Level):

- [ ]  Completed Application for Participation (this form)

- [ ]  Completed Delta College Student Physical Exam Form

- [ ]  Completed Hepatitis B Acknowledgement and Release Form and verification of vaccine, if necessary (see form)

- [ ]  Copy of Negative TB Test ( less than 1 year old)

- [ ]  Copy of MMR (Measles, Mumps, Rubella) immunization (Unless you were born before 1957)

- [ ]  Copy of Td (Tetanus) immunization, (current within 10 years)

- [ ]  Signed Current Criminal History Release form AND receipt for $10 from the Cashier's Office to pay for the iCHAT report.

- [ ]  Signed EMT Program Waiver and Release Form

- [ ]  Copy of valid Michigan Driver's License

- [ ]  Copy of valid Delta College ID card

*The Delta College exposure control plan for students enrolling in a clinical setting should be viewed before completing the Hepatitis B Acknowledgement and Release form . These documents may be viewed at:

https://sites.delta.edu/collegeinfo/Academics/Divisions/Shared%20Documents/EMS%20Forms/ExposureControl.pdf

Name

Student Number

Address

City

Zip

Primary Phone (

)

Secondary Phone (       )

\_\_\_\_\_\_\_\_

E-Mail

\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## Student Responsibilities:

1. During my EMS field experience, I will adhere to my training agency's policies and regulations. This includes, but is not limited to:

-  Maintaining a dependable work schedule

-  Observing confidentiality in the handling of information

-  Maintaining professional relationships with co-workers and customers

-  Completing all work-related assignments/projects in a timely fashion

-  Dressing and conducting myself in a professional manner (uniforms are required; see site supervisor for details)

2. Complete and return all EMS class-related assignments by the date provided by the EMS program coordinator, instructor and/or site supervisor.

I give permission to the ACE Office to release and use my official college records and documents referenced above for EMS Field Experience purposes.

Student Signature

Date

## For ACE Office use only:

READING LEVEL II:  COMPASS (61+)/ACT (14+)/ACCUPLACER (51+): Background Check Completed :\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(date)

Meeting with Terry:

(date)                                              (time)

Field Experience Site Agency Name:

Supervisor

E-mail

\_

\_\_

Documentation sent \_\_\_\_\_\_\_\_\_\_\_\_\_\_ (date)

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<small>Source: [https://www.delta.edu/programs/fire-science/_documents/emergency-medical-services-application.pdf](https://www.delta.edu/programs/fire-science/_documents/emergency-medical-services-application.pdf)</small>