Application for Admission to the Camp Emergency Medical Technician Program
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Today's Date *
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First Name *
Last Name *
Email
Date of Birth
Student ID number
If you have ever even STARTED an EMS class in Virginia, you already have a certification number assigned to you. If you do not know your certification number, please call 804-888-9120 to obtain it. If this will be your FIRST EMS class in Virginia, enter “none” in this field.
Virginia OEMS Certification #
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Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Camp History
Have you attended Paul D. Camp Community College in the past?
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Approximately how long ago did you last attend?
Have you taken Camp placement tests in the last 3 years?
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If you have not taken classes at Camp within the last three years, you should complete a new Application to the College and take the placement tests again
Educational Background
HS/GED
Institution
Location
Attendance/ Graduation/ Completion Year(s)
Degree/ Major/ Certificate
GPA or License Current?
Emergency Medical Technician
Institution
Location
Date Certifications Expires
Degree/ Major/ Certificate
GPA or License Current?
#1 College/ Higher Ed.
Institution
Location
Attendance/ Graduation/ Completion Year(s)
Degree/ Major/ Certificate
GPA or License Current?
#2 College/ Higher Ed.
Institution
Location
Attendance/ Graduation/ Completion Year(s)
Degree/ Major/ Certificate
GPA or License Current?
Previous Work Experience
Job #1
Employer
Years
Job #2
Employer
Years
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Job #3
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Employer
Years
Job #4
Employer
Years
Have you previously applied to an EMS Intermediate program?
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Date
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YYYY
Where you
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Have you previously been admitted to an EMS Intermediate program?
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If so, please name school and provide a brief explanation of your status when you left the program.
Have you ever had a license to practice EMS denied, revoked, suspended, or otherwise restricted?
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If Yes, Explain.
Is there any reason you might be unable to participate in the EMS Intermediate Program in a safe manner (illness, use of alcohol, drugs, narcotics, or chemicals)? Explain.
Have you committed, or been convicted of, any act which is a felony under the laws of Virginia or the United States or any act which is a misdemeanor under such laws and involves moral turpitude? (Moral turpitude is a legal concept that refers to "conduct that is considered contrary to community standards of justice, honesty or good morals). Explain.
In the space below you may give additional information, which you feel is pertinent to your application. You may include additional employment history, volunteer work, certificates, scholastic awards, work achievements, and/or professional organizations.
Please read carefully the following paragraphs:
I certify that this information is accurate and complete. I understand that giving incomplete or false information is grounds for denial of the application. I authorize Paul D. Camp Community College to request such information as necessary to verify my qualifications/suitability for the Nursing Program for which I have applied. I hereby release from all liability or damage those individuals who provide information related to my education or character and waive any rights of inspection of such information.
Nursing students are involved in the provision of direct patient care in medical facilities. Certain medical facilities require all nursing students to have a Virginia State Police criminal history and sex offender’s crimes against minors background investigation completed prior to the provision of patient care. Some facilities may also require drug testing for nursing students. Any student found guilty of a misdemeanor or felony prior to or during nursing education will be required to request an Exemption from Disqualification from each of the medical facilities to which they may be assigned during the program. If an exemption is not granted by the medical facility, the student will be unable to complete the requirements for the nursing program, and will not be permitted to progress through the program. Students will be required to submit similar documentation to the Virginia Board of Nursing when making application to take the registered nursing exam in Virginia. The Board of Nursing can deny licensure to any applicant who has filed false credentials, who has falsely represented facts on the application for licensure, and/ or who has committed a felony or misdemeanor. In addition, certain health care facilities may not hire individuals who have committed a felony or misdemeanor.
I understand that the responsibility for providing all transcripts and documentations to the nursing office lies with the applying student. Failure to provide required documents will be grounds for non-acceptance. I understand that the following documents are required
1. Official transcripts from high school or GED scores, colleges, and other higher education facilities
2. Evidence of U.S. citizenship or authorization to reside in the United States
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