 501 Vine St., Scranton PA 18509 PARAMEDIC PRE-PROGRAM PREREQUISITES
All students are required to pay materials/registration fees prior to the start of class. Any student not paying these fees in full, will not be admitted into class. No exceptions will be made.
APPLICATION FOR ADMISSION PERSONAL INFORMATION
NAME: _______________________________________ SS#: ___________________
Address _______________________________________ DOB ___________________
________________________________________ AGE ___________________
PHONE NUMBER ______________________________ _______________________ Home Work
DATES
Date of Interview ______________________ By _______________________________
Date of Acceptance ______________________By _______________________________
GENERAL INFORMATION
EMT CERTIFICATE EXP DATE ________________________ STATE ______________
ALS AFFILIATE _________________________________________________________
ACADEMIC
Pre-Admission Test Date _____________________________________________________
Interview Date _____________________________________________________________ Paramedic Training Institute
LACKAWANNA COLLEGE PARAMEDIC TRAINING INSTITUTE HEALTH INFORMATION FORM
EVERY APPLICANT FOR ADMISSION MUST COMPLETE THIS FORM:
Name __________________________________________________ Sex _________
Address __________________________________________________________________ Phone __________________________________________ Date of Birth ______________
PERSONAL HISTORY
1. Have you lived in close contact with anyone who had Tuberculosis: No __________ Yes _________ Explain ________________________
2. Have you ever had any of the following? None check here ___________________ ___Rheumatic Fever/ ___ Diphtheria ___Allergies (specify)_____ Cholera ___ Poliomyelitis ___ Heart Disease ___ Gland Trouble ___Hernia ___ Hay Fever/Asthma ___ Tuberculosis ___ Diabetes ___ Food Sensitivity ___ Speech Disorder ___ Epilepsy ___ Recurrent Headaches ___ Kidney Disease ___ Scarlet Fever ___ Convulsions/Blackouts ___Nervous Tendencies ___ Bone/Joint Trouble
If checked, please explain: ______________________________________________
LAST DATES OF IMMUNIZATIONS
___ Small Pox ___ Tetanus Toxoid ___Polio ___ Tuberculosis
3. Among your blood relatives, is there any history of /or present illnesses from the following?
4. Dates of significant injuries or operations which you have had:
If none, check here: _______
Injury or operation? ___________________________ Date ______________ Explain ________________________________________________________
5. Based on your most recent physical examination, do you have any physical limitations which would effect your participation in the classroom or activities such as physical education?
If no, check here _______
Yes, explain _________________________________________________________
6. Date of last chest x-ray? _____________________ Findings ____________________
7. Do you presently feel the need for Psychological or Health Counseling?
If not, check here ________
Check services desired:
Health Counseling ______ Psychological Counseling _____
EMERGENCY INFORMATION
1. In case of emergency, person to be contacted:
Name ________________________________________________________
Address ______________________________________________________ Phone_______________________ Relationship ______________________
2. In time of an emergency, I hereby authorize and direct the college to send me to the hospital or physician most readily accessible, and/or to administer necessary emergency care.
3. Type of Insurance/Plan Number __________________________________________
MEDICAL HEALTH FORM
Student Name ________________________________________________________
REQUIRED MEDICAL IMMUNIZATIONS (to be completed by Physician)
Tetanus (booster every 10 years) Date of last immunization _________________
Polio Date of last immunization _________________
Measles-Mumps-Rubella (MMR) Date of last immunization _________________
*Hepatitis B Vaccine Date of last immunization _________________ RECOMMENDED MEDICAL IMMUNIZATIONS
Influenza Date of last immunization _________________
Typhoid Date of last immunization _________________
If the physician feels certain immunizations are not necessary, please include a statement to that effect.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________ __________________________
Physicians Signature Date
*Note: If student declines to be immunized against Hepatitis B, a declination statement must be provided. Paramedic Training Institute
HEPATITIS B DECLINATION STATEMENT
I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) injection. I have been given the opportunity to vaccinate with Hepatitis B vaccine and decline at this time.
I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B Vaccine I will do so at my own cost.
______________________________________________ ___________________________ Student Signature Date
Paramedic Training Institute
FINANCIAL INFORMATION In addition to previous program prerequisites, students must fill out appropriate financial aid applications. An appointment can be made by calling the Lackawanna College Financial Aid Office at 961-7859. Registration Fee $ 100.00
(Fee is non-refundable and must be submitted with the application. Testing will not be scheduled until fee is paid.) Uniform Fee $ 120.00 (Fee is non-refundable and due upon acceptance into the program.) Books and Clinical Software $ 560.00 (Fee is non-refundable and due upon acceptance into the program.) All fees, including registration, uniform and books must be paid in full before the semester begins. Tuition: First Semester $4,800.00 Second Semester $4,800.00 Total cost for the program $10,380.00 *Students who qualify may receive funding through Financial Aid to cover the full cost of tuition.
Financial Aid InformationLackawanna College makes every effort to help students meet their educational expenses. All students are encouraged to complete a Free Application for Federal Student Aid (FAFSA), which are available in the Financial Aid Office. The Federal Pell Grant and several loan programs may be available to eligible paramedic students. Please call 570-961-7859 to schedule an appointment with Mrs. Grasso. Business Office Information |
