Emergency Medical Services (EMS) Program Application

Step 1 of 3

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

What county in Texas do you live in?(Required)

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

Phone(Required)

Date of Birth:(Required)

What City, State & Country were you born in?(Required)

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

Gender:(Required)

Emergency Contact(Required)

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)

Do you need accommodations under Section 504?(Required)

Section 504 Accommodations — Action Required

Students who require Section 504 accommodations must contact Kilgore College’s Accommodations & Disability Services before classes begin to ensure accommodations are in place. It is the student’s responsibility to initiate contact so Section 504 supports can be provided at the start of the term.

Visit Accommodations & Disability Services

I understand that it is my responsibility, as a student in the EMS program, to contact Kilgore College’s Accommodations & Disability Services department to arrange Section 504 accommodations before classes begin.(Required)
Yes, I understand.

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

Please note: A $300 deposit will need to be paid before the first day of class. EMS staff will notify you when the non-refundable deposit may be made and when the Remind class is available for sign-up.
1. EDUCATION REQUIREMENTS
Proof of high school completion:
Completed
Please upload a copy of your: Diploma, Transcript (can be an unofficial copy) or GED
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
Completed
What is the date of your most recent TB Skin Test (within 1 Year)?
MM slash DD slash YYYY

What is the date of your most recent T-Dap (within 10 Years)?
MM slash DD slash YYYY

What is the date of your most recent Hep B Vaccination (less than 1 Year or Neg Titer)?
MM slash DD slash YYYY

What is the date of your most recent MMR?
MM slash DD slash YYYY

What is the date of your most recent Flu Vaccination (annual)?
MM slash DD slash YYYY

What is the date of your most recent Varicella Vaccine (or proof of Chicken Pox vaccine)?
MM slash DD slash YYYY

Upload copies of your vaccination documents below.
Max. file size: 256 MB.

Max. file size: 256 MB.

Max. file size: 256 MB.

Max. file size: 256 MB.

If you are applying for the Paramedic program, 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

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.

Acknowledgment Statement(Required)
I affirm that all information I have provided on this form is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in immediate dismissal from the program.
I agree.

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Emergency Medical Services (EMS) Program Application

Section 504 Accommodations — Action Required

1. EDUCATION REQUIREMENTS

2. VACCINATIONS

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