Paramedic Program Admissions Application

Paramedic Program
Admissions Application
Application Information Thank you for your interest in the Emergency Medical Institute's Paramedic Program. To have your application considered for this program, you must complete and submit your application along with all supporting documentation.

To be eligible for this program, you must have:

1) NYS Emergency Medical Technician Certification, or higher. 2) Possess a valid New York State Driver’s License (or equivalent) 3) Possess a high school diploma (or equivalent) 4) Be eighteen (18) years of age or older at time of application 5) Pass a criminal background investigation verifying that candidate is compliant with Section 800 6(f) of the New York State EMS Code 6) Successfully complete entrance assessment exam with an average of 75 or better. Applicants must submit the following supporting documents for review: 1) Copy of your NYS EMT Certification, or higher. 2) Copy of your high school diploma (or equivalent) 3) Copy of your New York State Driver"s License (or equivalent) 4) Two Reference Letters: One (1) Professional Letter of Recommendation (Individual must have direct knowledge of your clinical practice as an EMT) and one (1) Personal Character Reference Letter Please complete all relevant sections of this application as accurately as possible. Individually scanned copies of your NYS EMT Certification, Driver's License, and High School Diploma are to be submitted with this application. Reference Letters may be submitted at a later date.

PERSONAL INFORMATION
PLACE OF BIRTH:*
Do you have a valid driver"s license?*

YESNO
State:*
License #:*
If you do not possess a valid driver"s license, you may not participate in this program. In addition to a significant amount of travel necessary to get to clinical sites, vehicle operation is contained within the Functional Job Responsibilities for an EMT/Paramedic Policy Statement issued by the New York State Bureau of EMS.

PERSONAL INFORMATION
Are you eligible to participate in the Paramedic Program under applicable U.S. Law?(Please refer to the Department of Homeland Security (DHS) website to verify eligibility.)
I am eligible*

YESNO
If you do not meet the eligibility guidelines detailed by the Department of Homeland Security and applicable law, you may not participate in this program.

EDUCATION
List your previously attended education institutions, beginning with high school.
NAME OF HIGH SCHOOL:*
STREET ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
Did you graduate?*

YESNO
YEAR GRADUATED*
If you did not graduate, do you have a High School Equivalency Diploma?*

YESNO

EDUCATION
Did you attend college?*

YESNO

EDUCATION
College Level Education (First Attended):
NAME OF SCHOOL:*
STREET ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST ATTENDED:*

MonthDayYear
Date
LAST ATTENDED:*

MonthDayYear
Date
GRADUATED:*
G.P.A.:*
DEGREE AWARDED
Did you attend another college?*

YESNO

EDUCATION
College Level Education (Last Attended):
NAME OF SCHOOL:*
STREET ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST ATTENDED:*

MonthDayYear
Date
LAST ATTENDED:*

MonthDayYear
Date
GRADUATED:*
G.P.A.:*
DEGREE AWARDED
Did you attend another college?*

YESNO

EDUCATION
College Level Education (Additional):
NAME OF SCHOOL:*
STREET ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST ATTENDED:*

MonthDayYear
Date
LAST ATTENDED:*

MonthDayYear
Date
GRADUATED:*
G.P.A.:*
DEGREE AWARDED

Additional Academic Information:
Were you ever on academic probation?*

YESNO
If yes, please explain:*
Were you ever suspended or dismissed from an education institution?*

YESNO
If yes, please explain:*

EMPLOYMENT HISTORY (most recent or relevant employers)
Volunteer work, for the purposes of this application, is considered employment. Please detail consistent, long term volunteer work with an agency as employment and list "Volunteer" as an Industry type. Consistent and long term is considered 20 hours or more per month for a period of greater than 12 months.
Have you ever been employed?*

YESNO

MOST RECENT EMPLOYER
EMPLOYER NAME:*
INDUSTRY TYPE:
ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST EMPLOYED:*

MonthDayYear
Date
LAST EMPLOYED:*

MonthDayYear
Date
If still currently employed, please use the date of application submission.
Did you have an employer prior, or in addition, to this one?*

YESNO

EMPLOYER #2
EMPLOYER NAME:*
INDUSTRY TYPE:
ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST EMPLOYED:*

MonthDayYear
Date
LAST EMPLOYED:*

MonthDayYear
Date
If still currently employed, please use the date of application submission.
Did you have an employer prior, or in addition, to this one?

YESNO

EMPLOYER #3
EMPLOYER NAME:*
INDUSTRY TYPE:
ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST EMPLOYED:*

MonthDayYear
Date
LAST EMPLOYED:*

MonthDayYear
Date
If still currently employed, please use the date of application submission.

EMERGENCY MEDICAL SERVICES EXPERIENCE
You should have a minimum of one (1) year experience as a practicing EMT with a response agency handling emergency 911-type assignments, three (3) years experience is preferred. If you listed EMS agency (or agencies) under employment history, please use the one with the longest amount of service in this section. Volunteer EMS agencies can also be listed in this section.
EMS AGENCY NAME:*
ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST EMPLOYED:*

MonthDayYear
Date
LAST EMPLOYED:*

MonthDayYear
Date
If still currently employed, please use the date of application submission.
Did you have another EMS agency prior, or in addition, to this one?*

YESNO

EMS AGENCY NAME:*
ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST EMPLOYED:*

MonthDayYear
Date
LAST EMPLOYED:*

MonthDayYear
Date
If still currently employed, please use the date of application submission.
Did you have another EMS agency prior, or in addition, to this one?*

YESNO

EMS AGENCY NAME:*
ADDRESS:*
CITY:*
STATE:*
ZIP CODE:*
FIRST EMPLOYED:*

MonthDayYear
Date
LAST EMPLOYED:*

MonthDayYear
Date
If still currently employed, please use the date of application submission.

Criminal Conviction and Background investigation Policy The criminal conviction policy for the Paramedic Program is in accordance with requirements set forth by the State of New York NYCRR 10 800.6 (f) (Part 800), and Bureau of EMS Policy 18-01 Certification for Individuals with Criminal Convictions (Policy Statement-Criminal Convictions) (Download Policy Statement PDF). I have been made aware of the criminal conviction policy for the program and I understand that if I do have a criminal conviction, and I decide to enroll in the program, that upon graduation, I may not be eligible to take the New York State Certification Examination for Emergency Medical Technician and/or Paramedic. I further understand that without such certification, I may be unable to work in New York State in that professional discipline.
I am aware of the Criminal Conviction and Background Investigation Policy.*

YESNO
You must indicate that you are aware of the policy to continue with the application.

Site Selection: Please select a primary site from which you will be attending the program. Please understand that there are limited seats available at the satellite locations and all seats will be filled on a first-come, first serve basis once an applicant is accepted into the program. We will do our best to accomodate your request, and will advise you of any alternatives if necessary.
Primary Site Selection:*

Lake Success (Main Location)South Shore University Hospital-Bay Shore (Satellite #1)
Application Attestation I certify that by indicating "YES" below and submitting this application, that the information within this application is complete and accurate to the best of my knowledge. I further acknowledge that this will serve as my electronic signature for the purposes of this application process.
Attestation*

YESNO
If yes, type your full name in the area provided.*
You must indicate "YES" before submitting your application for consideration.

SUPPORTING DOCUMENTATION
Professional and personal character reference letters are not required at time of application submission; however, these letters are required before an application will be presented to the Admissions Committee. You may submit multiple files; however, form response times vary. Please do not close the window or hit the browser back control as you will lose all previously entered data.
Scanned copies of NYS EMT Certification, High School Diploma, (or GED) and Driver"s License.*

Select File

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Thank you for completing the online application for the Paramedic Program. Please click "Submit" to send your application. You will receive a confirmation e-mail containing your responses for review.

You will be contacted by our staff to begin the assessment process.

Please obtain your references as soon as possible. One (1) Professional Letter of Recommendation (Individual must have knowledge of your work or study habits) One (1) Personal Character Reference Letter.

A copy of the Professional Letter Template will be attached to the autoresponder email you receive after submitting this application.
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