B-1502-11c EMT Program Registration February 2015

when
completed
February Monday/Wednesday Course 2015 EMT Course Program
Registration Checklist
Go to www.lvapec.com and set up a new user account and register online for the Basic
Program. This will reserve your spot for the course. The $100.00 deposit will be applied to
your tuition and is non-refundable.
Complete this packet as soon as possible after completing registration online. Enrollment is
not confirmed until all required documentation is completed and turned in.
The following documents must be received ASAP after completing online Registration and no later
than February 6th, 2015:
REQUIRED
Completed EMT-Basic Program Registration Checklist
Copy of government issued photo ID
Copy of GED, High School or College Diploma, or transcripts
Demonstrated vaccination (3 step) against Hepatitis B and Flu OR submit Declination of
Vaccination form(s)
Complete negative 10 panel urine test (not greater than 30 days old). We need a copy of the
results provided by your employer or if done at Global Safety Network results come
electronically to us.
Copy of a negative Two Step TB Skin Test or negative chest x-ray within the past 12 months.
Background check provided by Precheck to include national criminal Background check, OIG and
Sexual Offender list (not greater than 30 days old.
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Page 10
Page 10
Page 11
Once completed, complete packets can be mailed or dropped off at:
AMR Las Vegas
Attn: Kristin Woods
7201 W. Post Road
Las Vegas, NV 89113
OR
Faxed to 702-221-2155 or emailed
to [email protected]
You will receive confirmation of receipt of packet within one week and acceptance within one week or after
results of the Drug Test, Background Check and negative TB Test or supporting documentation received. If at
any point you have any questions, please contact us at [email protected]
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Date: __________________________
Program Start Date: February 9th, 2015
Applicant Information:
Name: ________________________________________________________________________________
Cell Phone: ____________________________ Home Phone: ____________________________________
Email Address: __________________________________________________________________________
Address: ____________________________________
Date of Birth: __________________________
____________________________________________
Last 4 of Social:_________________________
____________________________________________
Shirt Size: _________________
Name of Sponsoring Agency (if applicable): ___________________________________________________
Supervisor/Contact : _____________________________ Contact Phone Number: __________________
Education:
Schools Attended
Major and Location
High School
College
Other
Graduate
Last Year
Attended
 Yes
 No
 Yes
 No
 Yes
 No
Current Certification Expiration Dates:
CPR: __________________
Other: ________________
EMT Training Background:
EMT/EMT-Basic Training
School/Institution Name: ________________________________________________________________
City/State: _______________________________ Instructor: ___________________________________
Course Completion Date: ________________________________________________________________
IN CASE OF EMERGENCY NOTIFY: (Person NOT living at same address)
Name: ______________________________________________ Relationship: _________________
Address: ____________________________________________ Phone: ______________________
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EMT Program Enrollment Agreement
Program Name: B-1502-11c
Start Date:
February 9th, 2015
Instruction for this course will be held at:
American Medical Response-Las Vegas
7201 West Post Road
Las Vegas, NV 89113
Instructor:
Kristin Woods
Agreement for Education Services: This is an Enrollment Agreement for Emergency Medical Technician (EMT)
education to be provided to the student named below by Las Vegas Academy for Prehospital Emergency Care
(LVAPEC). This contract is a legally binding instrument, operative on the first day of instruction, when signed
by the student and accepted by the school.
_________________________________________
STUDENT NAME
_____________________
STUDENT ID NUMBER
Print first and last name legibly to avoid enrollment
delays
Course Title or Education Service:
Total Number of Clock Hours to be Completed:
Last four of Social Security Number
Class Times:
Didactic/Clinical Completion Date:
Total Fees, Charges, and Expenses:
Emergency Medical Technician (EMT)
156 Didactic Hours
24 Clinical Hours (minimum)
8 Hours Community Service
Total: 188 Hours
0900-1700 every Monday/Wednesday (with
the exception of Holidays)
April 30th, 2015
$ 1365.00
FOR OFFICE USE ONLY
Received: ______________________ By: _________________________ Payment Method: ______________________
Documentation Verified: __________________________
Sponsoring Agency Verification: ____________ Agency: ______________________ Contact: ____________________
Program: _______________________________________________
Approved: _____________________________________________
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Total Fees, Charges, and Expenses Breakdown
Deposit/Enrollment Fee
$100.00
Tuition
$1265.00
This fee is non-refundable upon
enrollment.
Deposit/enrollment fee + tuition
= total fees of $1365.00
____ (initial)
Students Right to Cancel / Refund Policy
1. The contract for school may be canceled by the first day of class to receive a full refund, less the NonRefundable Enrollment Fee of $100.00.
2. Withdrawal or dismissal from this course after the first day of class but before completion of 60% of
the course dates will entitle the student to a pro-rata refund of any unused portion of the $1365.00
less the Registration Fee. (See Page 12). The student will be responsible for payment in full of all
outstanding balances at the time of withdrawal or dismissal.
3. Cancellation MUST be made IN WRITING to the Program Coordinator. A request to withdraw may be
mailed or hand delivered to the address listed above. If the amount paid is more than the amount
owed for the time attended, a refund will be made within 45 days of withdrawal. If the amount owed
is greater than the amount already paid, payment in full of the outstanding balance will be required.
For the purpose of determining the amount owed for time attended, a student shall be deemed to have
withdrawn from the course when any of the following occurs:
a. The student notifies the school, in writing, of withdrawal or the actual date of withdrawal.
b. LVAPEC terminates enrollment.
c. The student fails to attend classes as outlined in the policies and procedures distributed on the
first day of instruction. In this case, the date of withdrawal shall be deemed to be the last date of
recorded attendance.
4. Refunds to Third Party Payor or Student Loan Programs:
If any portion of a student’s tuition and fees were paid by a third-party individual, organization, or
federal student financial aid funds, any remaining amount of the refund will be used to repay the thirdparty organization. Any remaining amount will then be paid to the student. If there is a balance due,
the student will be responsible for payment of the amount due to LVAPEC.
5. A full refund will be offered to military personnel presenting orders for extending deployment. All
other persons will fall into the deduction category listed above.
____ (initial)
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Program Payment Schedule
Total Fees, Charges, and Expenses:
$1365.00
Please initial next to the intended Payment Option.
OPTION 1 (Pay In Full)
_____(Initial)
Payment
Payment 1
Amount
$1365.00 (including
application fee)
Due Date
September 28, 2014
OPTION 2 (Payment Plan)
Payment plans are not available for this course. Full Payment is due September 28, 2014. The student is able to make
payments up to that date at www.lvapec.com.
All fees will be paid utilizing the online registration at www.lvapec.com.
Any payment must be pre-approved in writing with the Program Coordinator. Failure to adhere to the payment plan will
result in removal from the class.
Attorney Fees: I understand that in the event of any action taken by LVAPEC/EMSC to collect all balances due,
LVAPEC/EMSC shall be entitled to an award of attorney fees, collection fees and other costs resulting from this collection
action.
Returned Check Fee: LVAPEC will charge a $25.00 processing fee for each check returned by the bank for non-sufficient
funds.
This contract is a legally binding instrument, which becomes operative on the first day of instruction when signed by the
student and accepted by the school. LVAPEC reserves the right to cancel this agreement, for any reason, until the first day
of instruction. The student will be notified in writing of cancellation.
____________________________________
Signature of Student
__________________________
Date
____________________________________
Student Printed Name (Print legibly)
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Uniform Requirements
Students will be given one (1) LVAPEC t-shirt on the first day of class. Additional t-shirts will be available for
purchase during the class.
The student is responsible for purchasing and wearing:
-Navy Blue Trousers
-Black Belt, 1 ¾” with silver buckle
-Black, Polishable boots or Shoes, non-skid with closed toe and heel
____ (initial)
Books
Students must have the book on the first day of class.
Package ISBN-10:0133457974
This package contains:


Prehospital Emergency Care, 10th Edition
By Joseph J. Mistovich, Keith J. Karren, Brent Hafen|©2014|Paper ; 1440 pages
My BradyLab with Etext Student Access Code
For Brady: www.bradybooks.com Use Coupon Code Hicks14 for a 20% discount and free shipping.
____ (initial)
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Reasonable Accomodations
Please initial all that apply – Enrollment application cannot be accepted without initials.
___
___
___
___
___
Learning Disability
Physically Handicapped
Blind/Visually Impaired
Deaf/Hearing Impaired
Other (please explain) ____________________________________________________________
___ No Disabilities
Students with disabilities must provide written verification , addressed to the LVAPEC Program Coordinator, of
their disability, to include identification of their educational limitations due to their disability, from a qualified
medical examiner, PRIOR TO THE FIRST DAY OF THIS CLASS. LVAPEC instructional staff will determine if
reasonable accommodation for disability is needed or if it will alter this course of instruction and whether an
alternative accommodation is available. Students will be notified in writing of accommodation decision prior
to the first day of class. Any student whose disability cannot be accommodated will receive a full refund of all
tuition and fees paid.
____ (initial)
Release for use of Photo or Likeness
By initialing below, I acknowledge that the photo, image, quote, or other reproduction of my image, voice, and
our other personal attributes taken by LVAPEC, Medicwest, AMR or EMSC employee or their designee is given
voluntarily and I confirm my permission that such materials may be used for marketing or other related uses.
I understand and acknowledge such information may be in the public view and I acknowledge that I have not
been promised any compensation for the use of such materials.
I understand and acknowledge that I am responsible to notify LVAPEC, Medicwest, AMR or EMSC or their
designee prior to any photo, image, quote or other reproduction of my image, voice, and or other personal
attributes that I elect not to opt out of this agreement, and that I am responsible to remove myself from
exposure to any photo, image, quote or other reproduction of my image, voice and other personal attributes.
____ (initial)
Background Check and Drug Test
By initialing below, I acknowledge that I must start the process of the Background check by July 22, 2014.
Results not conforming to LVAPEC Policies and Procedures, or failure to submit these by the set assigned date
will result in termination from the course.
____ (initial)
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Questions, Complaints or Concerns
For any questions, complaints, or concerns that cannot be resolved with your instructor, please contact:
Managing Director:
Eric Dievendorf
LVAPEC
9 W. Delhi
North Las Vegas, NV 89032
____ (initial)
I do hereby certify the following:
1. I am the applicant named, and that I am requesting admission to the Las Vegas Academy for
PreHospital Emergency Care (LVAPEC) Program;
2. I understand that my application is not complete until all results of the background check, drug test, TB
Test or supporting documentation and all other required copies of documents are received by LVAPEC;
3. I understand that completion of the intermediate program does not guarantee NREMT or Southern
Nevada Health District Certification;
4. I understand that LVAPEC does not offer any formal placement services for any EMS company or
medical establishment;
5. I verify by my signature below that all statements made in this application are true and complete to
the best of my knowledge. I understand that any false statements or incomplete information may be
cause for rejection of my application or discharge from LVAPEC.
6. I have read, understand and agree to my rights and responsibilities, and that the institution’s
cancellation and refund policies have been clearly explained to me. I understand that continued
enrollment and course completion is dependent upon the attendance and grading policies as outlined
in LVAPEC’s intermediate course policies and procedures to be received on the first day of instruction.
I understand that I am financially responsible for the total charge of $1365.00 as detailed in this
contract. I understand that there are no refunds available to me after completion of 60% of the
program, and that I will be responsible for payment of the full tuition of $1365.00 after completion of
60% of the program.
_________________________________________
Signature of Student
_______________________________________
Date
_________________________________________
Student Printed Name (Print Legibly)
__________________________________________
Signature and Title of School Official
_______________________________________
Date
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Hepatitis B Vaccination Declination and/or Flu Vaccination Declination
Please fill out both parts and attach any supporting documentation.
Print Name______________________________________________________ Last 4 of Social_____________
Hepatitis B Declination
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be
at risk of acquiring Hepatitis B (HBV) infection. I understand at any point I can contact a clinic of my choice to
receive the immunization. I understand that by not having this vaccination that I am at continued risk of
acquiring Hepatitis B, a serious disease.

I have been previously vaccinated with the Hepatitis B Vaccine, but do not have supporting
documentation.
Date Completed_________________ Titer Results__________

I have not been previously vaccinated with the Hepatitis B Vaccine, however I decline the
vaccination at this time.

Other______________________________________________
Flu Declination
I understand that due to my occupational I may be at risk of acquiring the flu. I understand at any point I can
contact a clinic of my choice to receive the immunization. I understand that by not having this vaccination
that I am at continued risk of acquiring the flu, and may also be required to wear a mask by the hospital
during clinicals.

I have been previously vaccinated with the flu vaccine, but do not have supporting
documentation.

I have not been previously vaccinated with the flu vaccine, however I decline the vaccination
at this time.

Other______________________________________________
Student Signature: _________________________________________________ Date:__________
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Instructions for Drug Screening, Medical Testing, and Immunizations for
Las Vegas Academy for Prehospital Emergency Care
LVAPEC has partnered with Global Safety Network (GSN) to streamline the required student drug screening,
medical testing, and immunization process. Once testing is completed, results from Global Safety Network will
be provided electronically directly to LVAPEC admissions staff. If the student chooses to do the TB screening or
any immunizations at any other place then GSN, the student is responsible to provide the needed
documentation to LVAPEC.
Should the student choose to undergo the drug screening process at any other testing facility, results must be
faxed directly to LVAPEC at 702-221-2155. ABSOLUTELY NO HAND DELIVERED DRUG TEST RESULTS WILL BE
ACCEPTED.
REQUIRED:
Drug Testing:
Submission of a negative 9 panel drug screen (not greater than 3 months old) is a requirement for admission.
Proof of Negative TB Skin Test or X-Ray:
Submission of a negative Two Step TB Skin Test or negative chest x-ray within the past 12 months is a
requirement for admission. Documentation of a negative TB skin test within the past 12 months provided by
an employer is considered acceptable. The test must remain current throughout the duration of the course.
Payment for services is paid by the student to Global Safety Network.
Global Safety Network
702-696-1555
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INSTRUCTIONS FOR OBTAINING YOUR COMPLETE BACKGROUND CHECK FOR
Las Vegas Academy for Prehospital Emergency Care
Background checks are required on incoming students to insure the safety of the patients treated by students
in the clinical education program. You will be required to order your background check in sufficient time for it
to be reviewed by the program coordinator or associated hospital prior to starting your clinical rotation. A
background check typically takes 3-5 normal business days to complete. The background checks are conducted
by PreCheck, Inc., a firm specializing in background checks for healthcare workers. Your order must be placed
online through StudentCheck.
Go to www.mystudentcheck.com and select your School and Program from the drop down menus for School
and Program. It is important that you select your school worded as
Las Vegas Academy for Prehospital Emergency Care - EMT Basic and Intermediate
Complete all required fields as prompted and hit “Continue” to enter your payment information. The payment
can be made securely online with a credit or debit card. You may also pay by money order, but that will delay
processing your background check until the money order is received by mail at the PreCheck office. Texas
residents will pay $53.58 and New Mexico residents will pay $53.09. Residents in all other states will pay
$49.50. For your records, you will be provided a receipt and confirmation page of the background check
performed through PreCheck, Inc.
PreCheck will not use your information for any other purposes than the services ordered. Your credit will not
be investigated, and your name will not be given out to any businesses.
FREQUENTLY ASKED QUESTIONS:
Do I have to bring anything to the school? No. The school will receive results electronically.
Does PreCheck need every street address where I have lived over the past 7 years? No. Just the city and
state.
I selected the wrong school, program, or need to correct some other information entered, what do I do?
Please email [email protected], with the details.
How long does the background check take to complete? Most reports are completed within 3-5 business
days.
Will I get a copy of the background report? Yes. Log into www.mystudentcheck.com and click on “Check
Status”, and enter your SSN and DOB. If your report is complete, you may click on the application number to
download and print a copy. This feature is good for 90 days after submittal. After 90 days, you will be charged
$14.95 for a copy of your report, and will need to contact PreCheck directly to request this.
I have been advised that I am being denied entry into the program because of information on my report and
that I should contact PreCheck. Where should I call? Call PreCheck’s Adverse Action hotline at 800-203-1654.
Adverse Action is the procedure established by the Fair Credit Reporting Act that allows you to see the report
and to dispute anything reported. If you need further assistance, please contact PreCheck at
[email protected]
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Refund Schedule
Hours Completed
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68
72
76
80
84
88
ProRated Time Deduction
$59.87
$119.74
$179.61
$239.47
$299.34
$359.21
$419.08
$478.95
$538.82
$598.68
$658.55
$718.42
$778.29
$838.16
$898.03
$957.89
$1,017.76
$1,077.63
$1,137.50
$1,197.37
$1,257.24
$1,317.11
Registration/Early
Termination Fee
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
Refund
$1,205.13
$1,145.26
$1,085.39
$1,025.53
$965.66
$905.79
$845.92
$786.05
$726.18
$666.32
$606.45
$546.58
$486.71
$426.84
$366.97
$307.11
$247.24
$187.37
$127.50
$67.63
$7.76
0
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