Fillable Paramedic Application Packet (Colorado Mesa University)

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Paramedic Application Packet (Colorado Mesa University)

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Western Colorado Community College
2508 Blichmann Avenue
Grand Junction, CO 81505
Paramedic
Application Packet
If you have not completed your EMT certification, DO NOT use this application.
You must be a certified EMT or above to use this application.
Print the application, or save the application onto your computer, open and fill in the
information. When the form is complete, email to EMSProgram@coloradomesa.edu or turn in
to the EMT Office, Student Wellness Center, Room 205.
Starts In Fall Semesters ONLY
Last Name First Name MI Date
(please print legibly if hand writing)
__________________________
CMU/WCCC Student ID (700#)
Revised Jan 2021
Western Colorado Community College
2508 Blichmann Avenue
Grand Junction, CO 81505
Paramedic Applicant Information
PLEASE TYPE IN (OR PRINT LEGIBLY) ALL INFORMATION
Full Name (Last, First, Middle):
_______________________________________________________________________
Mailing Address (Street Address):
_______________________________________________________________________
City: _______________________________ State: ___________ Zip: ______________
Home Phone Number: (___)___________________
Cell Phone Number: (___)_____________________
Best number to contact you? Home Cell
E-mail Address:
________________________________________________________________________
CMU E-Mail Address:
________________________________________________________________________
(NOTE: You will receive a Colorado Mesa University email account upon acceptance to CMU/WCCC.
Please use your official CMU email address for all correspondence.)
Western Colorado Community College
2508 Blichmann Avenue
Grand Junction, CO 81505
List any current EMS certifications you hold, and why you desire to become a Paramedic.
Explain any training and/or education you have received to prepare you for the Paramedic
course.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name of High School and Date Diploma received, or G.E.D information
______________________________________________________________________________
______________________________________________________________________________
Shirt Size: ________________ Preference of: ☐ Male Style ☐ Female Style
Date of Birth: ____________________________
Other names used/ Maiden Name/ Aliases: _________________________________
Western Colorado Community College
2508 Blichmann Avenue
Grand Junction, CO 81505
Personal References
1: Full Name: ______________________________________Relationship: ____________________
Home Address: ___________________________________________________________________
Email Address:_____________________________________ Phone: ________________________
Occupation: _______________________________________ Years Known: ___________________
2: Full Name: ______________________________________Relationship: ____________________
Home Address: ____________________________________________________________________
Email Address:_____________________________________ Phone: _________________________
Occupation: _______________________________________ Years Known: ___________________
3: Full Name: ______________________________________ Relationship: ____________________
Home Address: ____________________________________________________________________
Email Address:_____________________________________ Phone: _________________________
Occupation: _______________________________________ Years Known: ___________________
In addition to these references above, you need to provide a letter of reference from your
Medical Director and/or Supervisor if you are currently with a responding agency, paid or
volunteer. If you have not been involved as a responder, a letter of reference from
your EMT (or higher level) instructor and a current employer will be accepted.
Western Colorado Community College
2508 Blichmann Avenue
Grand Junction, CO 81505
Additional Question
Is there anything in your background or experience that may negatively reflect on your
application or ability to complete the program? Please explain.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Disclaimer and Signature
I certify that the previous answers are true and complete. If this application leads to acceptance,
I understand that false or misleading information in my application or interview may result in
my dismissal from the CMU/WCCC EMS Program.
Signature
Date
click to sign
signature
click to edit
Western Colorado Community College
2508 Blichmann Avenue
Grand Junction, CO 81505
Paramedic Application Check List
ADMISSION TO COLLEGE
1. ☐ Complete Western Colorado Community College (WCCC) Application for Admission at:
http:www.coloradomesa.edu/wcc/apply.html (Current Colorado Mesa University (CMU) or
WCCC students, please disregard)
2. ☐ Submit official copy of High School Transcripts or G.E.D. scores, and/or College Transcripts
from previous colleges attended to: admissionsprocessing@coloradomesa.edu
3. ☐ TEAS Test Results (For Degree Seeking students)
4. ☐ Upon completion of your application and submission of your official transcripts, you will then
receive a letter of acceptance into CMU/WCCC along with your student ID number (also known
as a 700#)
PRE-ADMITTANCE REQUIREMENTS:
1. ☐ Background Check
a. The EMT, Advanced EMT, and Paramedic Programs require a background check which
can be completed through www.castlebranch.com (Use Passcode – cm75)
b. Colorado Bureau of Investigations- for Colorado residents:
(https://www.cbirecordscheck.com Go to the website and select Internet Background
Check. Then fill in all the information and get your document.
YOU MUST PRINT THIS OUT AND BRING IT IN TO THE EMS OFFICE! Fee is $5.00
2. ☐ Five (5) Panel drug screen. Lab of your choice. Must be within 45 days of the first day
of class.
ADMISSION TO THE PARAMEDIC PROGRAM
1. ☐ Fill out the Paramedic Application and submit to:
T. Troy Salazar or EMS Office 205
Paramedic Instructor Coordinator Student Wellness Center
tsalazar2@coloradomesa.edu 1060 Orchard Ave
Grand Junction, CO 81505
2. ☐ Submit a colored, enlarged copy of current, valid driver’s license
Western Colorado Community College
2508 Blichmann Avenue
Grand Junction, CO 81505
3. ☐ Physical examination (Must be able to lift 50 lbs. Examination must not be more than three (3)
months old)
4. ☐ Proof of the following immunizations:
• Two Measles/Mumps/Rubella
• Varicella
• Tetanus (current within 10 years)
• Hepatitis B (Series of three (3) immunizations)
• Influenza (must be current year)
• Current TB skin test. (Either a two-step TST within the past 12 months or proof of negative
TST documented for 2 years. If the student has proof of a one-step within the past 12
months, a one-step TST should be done)
5. ☐ Copy of Current EMT State Certification (student from outside Colorado must provide NR EMT
Certification and provide Colorado State certification as soon as it is obtained)
6. ☐ Copy of Current BLS CPR Card
7. ☐ Proof of successful completion of an EMT IV Certification course, and a Basic EKG course (attach
a copy of certificate(s) of completion)
8. ☐ Submit proof of professional liability insurance. Students may apply for insurance through the
National Professional Groups as a student. The website is www.hpso.com. Should students
choose to go through a different company, the policy must be comprehensive general liability
insurance covering bodily injury and property damage liability with minimum coverage limits of
$1,000,000 per occurrence/$2,000,000 general total limit, and medical professional liability
insurance with a minimum coverage limits of $1,000,000 per claim/$3,000,000 annual aggregate.
Paramedic student must be listed.
9. ☐ Submit proof of personal health insurance.
10. ☐ Other documentation as requested.
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Completed 16 May 2021

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