Name

Name Relationship

Address

City

Daytime Telephone Evening Telephone

Pager / Cel

Email

Social Security #

Have you ever previously applied for one of our paramedic programs?

Date(s):

Date of Birth

State ZIP

Address

City

Daytime Telephone Evening Telephone

Pager / Cel

State ZIP

yes

Personal Information

Emergency Contact

no

Have you ever previously applied for any SPCI courses?

Date(s):

yes no

Are you eligible for V/A benefits? yes no

Current Level of Certification

Current certification as an EMT-Basic in any state is a minimum prerequisite for this program

EMT-Basic EMT-Intermediate RI EMT-Cardiac

Other

Massachusetts # Date of Original Issue Exp. Date

Exp. Date

Exp. Date

Exp. Date

Exp. Date

Rhode Island # Date of Original Issue

National Registry # Date of Original Issue

Other State # Date of Original Issue

Licenses and Certifications (please submit photocopies of all certifications and licenses with your application)

Driver’s License # State

Page 1

Safety Program Consultants, Inc.306 Winthrop St., Taunton, MA 02780(800) 499-6428

Param

edic Class A

pplication

Other Licenses and / or Certifications

Education

Other

CPR

Name / Location Major Degree Obtained

High School

Trade School

College / University

Graduate School

How long have you been actively involved in Emergency Medical Services?

FF1 FF2 Hazmat CDL PALS ACLS

CPR / AED Instructor First Aid Instructor ETT EVOC

Date / Location / Instructor of initial EMT-Basic program:

Date / Location / Instructor of advanced level EMT program:

Essay QuestionsPlease use a separate sheet of paper to answer the following

1) Has your EMT certificate or authorization to practice ever been revoked or suspended?

Yes No

2) Have you ever been convicted of a felony in any state?

Yes No

3) Have you ever been convicted of any offense related to controlled substances?

Yes No

Yes, without reservation Yes, with some concerns Please contact me - I am not sure

If you answer “yes” to any of the following questions please explain in detail on another piece of paper

Page 2

1) What personal and professional goals have you set for yourself, and what have you done to fulfill them?

2) In essay form, please tell us what attributes you posses that would make you a good candidate for our paramedic program.

4) Are you able to make time commitments (including reliable transportation) for the required didactic and clinical requirements which average 26-30 hours per week?

Safety Program Consultants, Inc.306 Winthrop St., Taunton, MA 02780(800) 499-6428

Param

edic Class A

pplication

Safety Program Consultants, Inc.306 Winthrop St., Taunton, MA 02780(800) 499-6428

Param

edic Class A

pplication

Name

Reference 1Title / Position

Address

City

Daytime Telephone Evening Telephone

Email

State ZIP

Name

Reference 2Title / Position

Address

City

Daytime Telephone Evening Telephone

Email

State ZIP

Incomplete or illegible addresses may result in rejection of application.Please list two references not related to you. Each person will be contacted by SPCI.

Page 3

Upon receipt of this application, you will need to complete a pre-test consisting of 250 multiple choice questions covering math, reading, and general EMS knowledge. Pre-tests may be scheduled through the office Monday - Thursday 9:00 am - 4:00 pm at SPCI Taunton. Please allow three hours for this exam. You will also be required to attend an interview prior to acceptance.

Cost for textbooks required for this course are not included with the tuition. Textbooks may be purchased through the school; if you wish to purchase books from the school please indicate and sign below. Students who purchase textbooks from an outside source will be required to verify the correct publishers and editions prior to the beginning of class.

Upon acceptance into the Paramedic program, you will receive information for tuition payment. If you have any questions concerning tuition and tuition payment options please contact SPCI at (800) 499-6428. SPCI accepts cash, personal checks, money orders and most major credit cards.

I wish to purchase textbooks through the school and agree to pay the cost of these textbooks

I do not wish to purchase textbooks through the school and understand that it is my responsibility to acquire the correct textbooks prior to the first day of school. I further understand that failure to obtain the required textbooks will affect my class standing up to and including removal from the program.

Signature Date

Page 4

I hereby attest and affirm that I am committed to this EMT-Paramedic Education program and will make sufficient time available for its completion. I attest that I will pay all fees and tuitions incurred by myself while enrolled in this program as specified by my financial agreement. I also attest to the fact that all information provided by me is true and correct to the best of my knowledge. Any attempt to offer incorrect or fraudulent information will result in immediate withdrawal of this application, termina-tion from the program, and forfeiture of future program acceptance.

Safety Program Consultants, Inc. does not discriminate on the basis of race, creed, color, sex, age, nationality, or sexual orientation.

Please return this application along with all essay questions, photocopies of all applicable certifications and a check or money order for seventy five($75) dollars US to:

Safety Program Consultants Paramedic Applications306 Winthrop St.Taunton, MA 02780

Please consult and review this document with your own legal counsel if you have any concerns.

Signature Date

Ethnicity (optional - for statistical purposes only)African American

Hispanic

Asian

American Indian

White

Other

Param

edic Class A

pplicationSafety Program Consultants, Inc.306 Winthrop St., Taunton, MA 02780(800) 499-6428