EMT Course Application

First Name *

Middle Name

Last Name *

Date of birth *

Email *

Phone *

Address *

City *

State *

Postal code *

Do you have a SSN/EIN/TIN you can provide for certification? (required) *

Which Semester are you applying for *

Were you referred to LifeStart by a former graduate?

Enter the name of the program graduate who referred you.

Upon completion of the LifeStart Training & Consulting, LLC EMT Initial Course, the candidate will be required to answer questions regarding felony convictions, or deferred adjudication as part of the application process for certification by the National Registry and Texas Department of State Health Services. For information regarding your background history, please look at the following websites for their evaluation procedure and contact information:

*Texas Department of State Health Services, Criminal History Evaluation and EMS Investigations:

https://www.dshs.texas.gov/dshs-ems-trauma-systems/criminal-history

*National Registry of EMT’s Felony Conviction Policy

https://www.nremt.org/Policies/Certification-Policies/Criminal-Conviction

Certain technical, academic, and physical standards are required in health science professions:

EMT INITIAL COURSE TECHNICAL, ACADEMIC, AND PHYSICAL STANDARDS

Certain technical, academic, and physical standards are required in health science professions (See EMT INITIAL COURSE TECHNICAL, ACADEMIC, AND PHYSICAL STANDARDS). Are you able to meet the minimum technical, academic, and physical standards for this program? *

PRIOR TO ACCEPTANCE:

Application Phase 1

I. All applicants must provide one copy of each of the following:

1. _____Proof of high school graduation or GED (Texas Department of State Health Services requirement for certification)

2. _____Proof of Health Insurance

II. All applicants must provide written documentation from a health care professional for:

1. _____Proof of Varicella (Chicken Pox) immunity as shown by

a) _____physician documented history of the disease or

b) _____documentation of two immunizations or

c) _____a serum titer confirming immunity

2. _____Proof of a complete series of three injections of the Hepatitis B Vaccination or

a) _____a serum titer confirming immunity

3. _____Proof of two measles vaccinations (may be part of MMR) or

a) _____A serum titer confirming immunity or

b) _____Proof that the student was born prior to January 1, 1957 or

c) _____Physician documented history of the disease, regardless of date of birth

4. _____Proof of one mumps vaccination (may be part of a second MMR) or

a) _____A serum titer confirming immunity or

b) _____Proof that the student was born prior to January 1, 1957 or

c) _____Physician documented history of the disease, regardless of date of birth

5. _____Proof of one Rubella Vaccination (may be part of a second MMR) or

a) _____A serum titer confirming immunity or

b) _____Physician documented history of the disease

6. _____ Proof of Tetanus-Diphtheria and pertussis (Tdap) vaccination within the last 10 years

7. _____ Proof of the Influenza vaccine (Flu shot) for the current flu season. (This requirement only

applies for fall and spring semesters)

8. _____ Proof of initial bacterial meningitis vaccination dose or booster during the five-year period

preceding and at least 10 days to the first day of class or

a) _____ Proof that the student will be 22 years of age at the start of class if declaring

exemption from meningitis vaccine.

Application Phase 2:

(Once Phase 1 is complete you will receive instructions to complete this phase.)

I. All applicants must pass a criminal background check and drug screen no more than 30 days prior to the start of class. All applicants must be at least 18 years of age by the start of their first clinical.

II. Proof of two-step TB test (PPD skin test or chest x-ray) with a negative reading. TB skin test is only good for one year and they must be valid through the end of the course. This cannot be older than 90 days prior to the start of class.

Incomplete applications ARE accepted after the $50 non-refundable application fee is received, and a seat will be reserved for you. Do you understand and acknowledgethat the above items will be required prior to start of clinical rotations? *

Yes

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Application Fee *

$ 51.75

Application fee (includes $1.75 credit card processing fee)