Please attach a copy of your
EMT card here
Please attach a copy of your
CPR card here
Hudson Valley Community College
Paramedic Certicate Program Only
Supplemental Application
Name ___________________________________________________ SS # ___________________________
Mailing Address _____________________________ City __________________ State ______ Zip ________
Daytime Phone # _____________________________ E-mail ________________________________________
EMT # __________________ State _______________ Level _______________ Exp. Date _______________
Education: HS _______________________ Some College __________________ AS/AAS BS/BA. MS.
Applicant’s Statement and Signature
I, the applicant whose signature appears below this statement, acknowledge that the information set forth by me in
the above supplemental application is true and accurate. I also understand that it is my responsibility to maintain a
current CPR and NYS EMT certification throughout the Paramedic Program and that I will be required to sign a NYS
EMS student application (DOH-65) which states the following: I do affirm that I have not been convicted nor am I
currently charged with any crime(s). Failure to be able to sign the DOH-65 could result in my being ineligible to sit
for the NYS certifying examinations.
Signature of Applicant ___________________________________________________
Date __________________________
Please complete the second page of this sheet
Verification of Calls and Skills
Agency Name ______________________________________________________________________________
Chief Officer _______________________________________________________________________________
Phone number for Chief Officer/Supervisor _________________________________________________________
I hereby attest that ___________________________________________ is a member/employee of
(Applicant name)
___________________________________________________________ since _____________________.
(Name of organization) (date)
She/he has been certified as an EMT actively riding with this agency for ________ or ________ and has
completed more than 50 emergency calls.
She/he has been observed within this agency performing the following skills or actions and is capable of functioning
as an entry level EMT.
Patient assessment including vital signs
Patient lifting and moving
CPR
Hypoperfusion interventions
Airway management/Oxygen administration Immobilization/dressing/bandaging Medication assist
Verbal and written reporting including use of radios
I am unaware of any criminal or disciplinary actions pending against this applicant.
I am aware that this verification is part of an application to the Hudson Valley Paramedic Program.
Signature of Chief Officer/Supervisor _____________________________________________________________
Print name of Chief Officer/Supervisor ____________________________________________________________
Date __________________________
Medical Director’s Statement
I am aware of this Verification of Calls and Skills request made as part of the application process to the Hudson Valley
Paramedic Program. I feel this individual is competent to participate as a student and EMT in advanced level training
at this time.
Medical Director’s Name ______________________________________________________________________
(Please print name)
Medical Director’s Signature ___________________________________________________________________
Date ______________________________
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(years) (months)