General Information What location are you applying for?: *What location are you applying for? East Brunswick Elizabeth Jersey City EMS Lakewood Millburn-Short Hills Roselle RWJBarnabas Clara Maass RWJBarnabas Somerset Union Township Fire What class # are you applying for?: * What date does this course begin? *First Name *Last Name Date of Birth - mm/dd/yyyy *Email Student's Cell Phone Student's Home Phone Address 1 Address 2 City State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip Country Please list any medical conditions you have (this will be kept confidential and used in case of emergency).: Please list any medications you take (this will be kept confidential and used in case of emergency).: Please list any allergies you have (this will be kept confidential and used in case of emergency: *Will you be at least 18 years old before the last day of class and be interested in working for RWJBarnabas Mobile Health Services as an EMT after successfully passing the NREMT exam at the end of the course? If you answer yes, someone will contact you to discuss optional pathways to employment. YesNo Not sure yet *Are you on a rescue squad? YesNo In the process of joining one If you do volunteer on a rescue squad or are in the process of joining, which one? Emergency Contact Information *First Name *Last Name Emergency Address 1 Address 2 City State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip Country Emergency Contact Phone Emergency Contact Alternate Phone Acknowledgements 1. Student Authorization Form: By typing your name below, you indicate that you have read and agree to the information contained in this document listed in step 1 above. Please make sure you have read this document since you will be held accountable for its content. Student: Please type your name regarding acknowledgement 1. Parent/Guardian for Students Under 18: Please type your name regarding acknowledgement 1. 2. Performance Agreement: By typing your name below, you indicate that you have read and agree to the information contained in this document listed in step 1 above. Please make sure you have read this document since you will be held accountable for its content. Student: Please type your name regarding acknowledgement 2. Parent/Guardian for Students Under 18: Please type your name regarding acknowledgement 2. 3. Attendance Agreement: By typing your name below, you indicate that you have read and agree to the information contained in this document listed in step 1 above. Please make sure you have read this document since you will be held accountable for its content. Student: Please type your name regarding acknowledgement 3. Parent/Guardian for Students Under 18: Please type your name regarding acknowledgement 3. 4. Health Agreement: By typing your name below, you indicate that you have read and agree to the information contained in this document listed in step 1 above. Please make sure you have read this document since you will be held accountable for its content. Student: Please type your name regarding acknowledgement 4. Parent/Guardian for Students Under 18: Please type your name regarding acknowledgement 4. 5. Payment Agreement: By typing your name below, you indicate that you have read and agree to the information contained in this document listed in step 1 above. Please make sure you have read this document since you will be held accountable for its content. Student: Please type your name regarding acknowledgement 5. Parent/Guardian for Students Under 18: Please type your name regarding acknowledgement 5. 6. Technology Agreement: By typing your name below, you indicate that you have read and agree to the information contained in this document listed in step 1 above. Please make sure you have read this document since you will be held accountable for its content. Student: Please type your name regarding acknowledgement 6. Parent/Guardian for Students Under 18: Please type your name regarding acknowledgement 6. 7. Academic Policies & Procedures: By typing your name below, you indicate that you have ready and agree to the information contained in this document listed in step 1 above. Please make sure that you have read this document since you will be held accountable for its content. Student: Please type your name regarding acknowledgement 7. Parent/Guardian for Students Under 18: Please type your name regarding acknowledgement 7. 8. For Minors Only - to be completed by your Parent/Guardian: By typing your name below, you acknowledge your son/daughter has the maturity to participate in an Emergency Medical Technician program and authorize their enrollment in this course. You also agree to make sure your son/daughter will have transportation to and from the classroom and clinical rotation sites. Am I ready to submit? Check off each item below to make sure! When all boxes are checked you are ready to click submit. * I will be 16 years old or older before the first day of class. I have reviewed the attendance agreement carefully and verified my schedule will allow me to attend 100% of the classes. I have reviewed the attendance agreement carefully and verified my schedule will allow me to attend 100% of the classes. I understand I will need to complete a minimum of 10 additional hospital observation hours. I understand I will need to complete a minimum of 10 additional hospital observation hours that will be completed outside of the regular class schedule as required by state regulation. I am aware having a personal computer or tablet available to me during class will assist me in this program since RWJ uses an online learning management system. I am aware having a personal computer or tablet available to me during class will assist me in this program since RWJ uses an online learning management system. I have access to the internet and printer outside of class. I have access to the internet and printer outside of class. I have thoroughly read all documents in step 1 I have thoroughly read all documents in step 1. *Confirm Security Question below: