Emergency Medical Services (EMS) Program Application

Step 1 of 5

Which program are you applying for?(Required)

Class Dates: (found on previous page)(Required)

Registration will be accepted only if class space is available when this form is received.

*Tuition is non-refundable after first class day.

Social Security #:(Required)

(In order to help us protect your Social Security number, the college computer system will convert your SS# into your student ID# for your record.)

Sponsoring Agency (if applicable):

Name(Required)

First Middle Last

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

If you live in Texas, what county do you live in?

Phone

Date of Birth:(Required)

What City, State & Country were you born in?

City born in: State born in: Country born in:

Gender:

Emergency Contact

First Last

Emergency Contact Phone

Colleges and universities are asked by many, including the federal government, accrediting associations, college guides, newspapers and our own college/university communities, to describe the racial/ ethnic backgrounds of our students and employees. In order to respond to these requests, we ask you to answer the following two questions.

Are you Hispanic or Latino? (Are you a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Hispanic culture or origin?)(Required)

Please select the racial category with which you most closely identify:(Required)

Please select which applies:(Required)

Highest level of education:(Required)

Have you served or volunteered with any type of fire department/EMS service?(Required)

If you answered yes, where did you volunteer?

How did you learn about the KC EMS program?

If you selected "Other" how did you learn about us?

The application must be completed and submitted 30 days prior to the first day of class.

You will need to upload the following forms in order to complete your application:

Class Application (already completed on page 1)

Diploma, Transcript, or GED

Childhood Vaccinations and Current

Drug and Background Test

NIMS 100, 200, 700, and 800

CPR Card

Textbooks

Please note: A $300 deposit will need to be paid before the first day of class. You will also need to sign up for the Remind app. EMS staff will notify you when the deposit may be made and when the Remind class is available for sign-up.
1. EDUCATION REQUIREMENTS
Proof of high school completion:(Required)
Completed
Please upload a copy of your: Diploma, Transcript (can be an unofficial copy) or GED(Required)
Max. file size: 256 MB.
2. VACCINATIONS
According to Texas Administrative Code, Title 25, Part 1, Chapter 97, Subchapter B, Rule §97.64, any student taking part in direct patient contact will be required to have the following prior to clinical rotations:

Negative tuberculosis (TB) skin test (performed annually)

OR chest X-ray (performed every 3 years)

Flu vaccine (for current year)

Varicella vaccine, two doses (unless one dose was prior to age 13)

OR history of contracting varicella validated through a health care professional

OR serologic confirmation of immunity

Hepatitis B vaccine, 3-dose regimen

PLUS, Hepatitis B serologic proof of immunity (performed approximately one month after the third dose – must have antibody greater than 10)

Measles, mumps, rubella (MMR) vaccine, two doses

OR serologic proof of immunity

Tetanus, diphtheria, and pertussis (TDAP) vaccine within last ten years

Acceptable evidence of vaccines:

Vaccine administered after 9/1/99 shall include month, day, and year each vaccine was given

Documentation of vaccine that includes the signature or stamp of a physician/designee or public health personnel

An official immunization record generated from a state or local health authority, such as a registry

A record received from school officials

Vaccination & Certification Check List(Required)
Completed
What is the date of your most recent TB Skin Test (within 1 Year)?(Required)
MM slash DD slash YYYY

Upload a copy of your TB Skin Test documentation:(Required)
Max. file size: 256 MB.
What is the date of your most recent T-Dap (within 10 Years)?(Required)
MM slash DD slash YYYY

Upload a copy of your T-Dap documentation:(Required)
Max. file size: 256 MB.
What is the date of your most recent Hep B Vaccination (less than 1 Year or Neg Titer)?(Required)
MM slash DD slash YYYY

Upload a copy of your Hep B Vaccination documentation:(Required)
Max. file size: 256 MB.
What is the date of your most recent MMR?(Required)
MM slash DD slash YYYY

Upload a copy of your MMR documentation:(Required)
Max. file size: 256 MB.
What is the date of your most recent Flu Vaccination (annual)?(Required)
MM slash DD slash YYYY

Upload a copy of your Flu Vaccination documentation:(Required)
Max. file size: 256 MB.
What is the date of your most recent Varicella Vaccine (or proof of Chicken Pox vaccine)?(Required)
MM slash DD slash YYYY

Upload a copy of your Varicella Vaccine documentation (or proof of Chicken Pox vaccine):(Required)
Max. file size: 256 MB.

DRUG & BACKGROUND CHECK
Drug & Background Test(Required)
Completed
Criminal Background Check and Drug Screen Policy – Texas Administrative Code Compliance

Per Texas Administrative Code Title 25, Part 1, Chapter 157, Subchapter C, Rule §157.37 (e)(5), the following offenses disqualify individuals from EMS certification or licensure:

Conviction or deferred adjudication on or after September 1, 2009, for:

Murder

Capital murder

Indecency with a child

Aggravated kidnapping

Aggravated sexual assault

Aggravated robbery

Substance abuse offenses under Health and Safety Code, Chapter 481, where punishment is enhanced due to:

Use of a child in the commission of the offense (§481.140)

Commission of the offense in a drug-free zone with prior convictions (§481.134(c), (d), (e), or (f))

Sexual assault

Any offense committed on or after September 1, 2009, requiring sex offender registration under Code of Criminal Procedure, Chapter 62.

Students with any criminal history record are strongly encouraged to submit an initial DSHS EMS application (marked "Prescreen") for review by the Texas Department of State Health Services as early as possible. Fingerprints and processing fees will also be required.

Successful completion of a criminal background check and drug screen is required by clinical site providers to participate in school rotations. This ensures the safety and integrity of the clinical training environment. Drug and background screens are valid for 12 months. If your screening is set to expire during the program, a new screening is required two weeks before the expiration.

Drug Screen

Frequency:

Required upon entry into the Kilgore College EMS Program.

As needed during the program if there is reasonable suspicion of substance use.

Procedures:

Must be conducted by the approved vendor or as outlined in the Drug and Background Policy.

Any student or employer attempting to defraud the process or refusing participation will be immediately dismissed from the program.

Students or employers must notify the EMSP Clinical Coordinator or Director within 24 hours of any changes in status.

Approved Screening Agency

Drug and Alcohol Testing Compliance Services (DATCS)
450 E. Loop 281, Longview, TX 75605
Phone: (903) 500-2770

Background Check: Complete online at DATCS office.

Drug Screen: Performed on-site only at DATCS office.

Note: Additional charges may apply if further review is required for either the drug screen or background check.

Employer-Provided Checks

Costs: Students or employers bear all costs; Kilgore College is not responsible for these fees.

Submission Requirements:

Results must be sent directly from the testing/reporting agency to the Kilgore College EMS Clinical Coordinator or Program Director.

Reports must be FACIS and FCRA compliant.

Must include local, state, and federal checks, plus an OIG exclusion check.

Drug Screen Panels:

EMT/AEMT/Paramedic: 10-panel test.

Positive results require documentation from the testing facility verifying a valid prescription (additional charges may apply).

Positive results from non-prescription illicit substances (including marijuana and delta products) will result in removal from the program for no less than one year.

Student Responsibility

Reporting Changes: Students must inform the EMS Clinical Coordinator or Program Director of any changes in legal standing or drug test results within 24 hours during enrollment.

Consequences of Non-Compliance: Failure to notify the program of relevant changes will result in dismissal.

Print out this form, schedule your appointment, and upload it below once completed.
Upload Drug & Background Test Form here:
Max. file size: 256 MB.

REQUIRED COURSES (NIMS 100, 200, 700 & 800)
4. NIMS 100, 200, 700 & 800

Go to: https://training.fema.gov/nims/nims.aspx

Create an account for yourself and take the courses for ICS-100, ICS-200, ICS-700 & ICS-800. Be aware that you will need to create an account and follow all the steps required by FEMA for this website.

After each course, print out and keep the completion certificate for your records, and upload a copy of each certificate below.
Upload completion certificates for NIMS ICS-100, ICS-200, ICS-700 & ICS-800 :(Required)
Completed
Upload ICS-100 completion certificate:(Required)
Max. file size: 256 MB.
Upload ICS-200 completion certificate:(Required)
Max. file size: 256 MB.
Upload ICS-700 completion certificate:(Required)
Max. file size: 256 MB.
Upload ICS-800 completion certificate:(Required)
Max. file size: 256 MB.
5. CPR Card (AHA or ARC)
CPR Certified(Required)
Completed
CPR Expiration Date:
MM slash DD slash YYYY

Upload a copy of your CPR card:
Max. file size: 256 MB.
If you are applying for EMTA/Paramedic, upload any of the following documents for certifications you have.
EMTB: #
State:
Expiration Date:
MM slash DD slash YYYY

EMTA: #
State:
Expiration Date:
MM slash DD slash YYYY

EMTP: #
State:
Expiration Date:
MM slash DD slash YYYY

NREMT: #
State:
Expiration Date:
MM slash DD slash YYYY

Upload any other certifications you have:
Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.

6. PURCHASE TEXTBOOKS
Do Not Pay For Expedited Shipping. You Will Not Receive Any Faster!!!

Your textbook and Platinum Planner access must be purchased before the first day of class. It may be purchased from the link provided below. No Amazon purchases or Used Books.
Textbook ordered(Required)
Completed

Click on the button below to order your textbooks.

Once clicked your UN and LOGIN will be:
Username: Pearson
Password: welcome2
Order Textbooks
Remember: You will need to pay the $300 deposit before the first day of class.

Other items you will need to purchase within the first week of class:

KCEMS Polo x2

Student Badge / ID

Duty Pants, Belt, and Boots

Stethoscope

Pen Light

Trauma Shears

Blue Pens (Permanent, not erasable)

Menu

Emergency Medical Services (EMS) Program Application

1. EDUCATION REQUIREMENTS

2. VACCINATIONS

DRUG & BACKGROUND CHECK

Drug Screen

Approved Screening Agency

Employer-Provided Checks

Student Responsibility

REQUIRED COURSES (NIMS 100, 200, 700 & 800)

5. CPR Card (AHA or ARC)

6. PURCHASE TEXTBOOKS

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