ACC Advanced EMT Application

1
Choose the semester for which you are applying.* This field is required.This application period is for summer 2023. Our next application period will be in Spring 2024
Summer 2023
2
I am 18 years old or older.* This field is required.
True
False
3
I have a high school diploma or GED and can provide proof upon request.* This field is required.
True
False
4
I understand I must complete the Apply Texas application required by ACC OR I am already an ACC student.* This field is required.
True
False
5
I have completed an approved Texas Department of State Health Services EMT course and can provide a copy of a transcript and/or course completion certificate upon request.* This field is required.
True
False
6
I meet one or more of the criteria listed below:* This field is required.1. I have a valid, non-expired, active, non-suspended TEXAS EMT certification. 2. I have an approved EMT certification application from the Texas Department of State health Services and am awaiting my certification to go live in the Texas department of State Health Services.
True
False
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Applicant Name* This field is required.
First Name
Last Name
8
Applicant ACC Student Identification Number: *
9
Email* This field is required.Please provide the email address you monitor most often. All communication regarding your application will be sent to the email address you provide here. Please check your submission for accuracy before moving on to the next question.
10
Phone Number* This field is required.Please provide the best phone number for you in case we need the contact you for additional information regarding your application.
Area Code
Phone Number
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Mailing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Physical AddressYou only need to complete this section if your Physical Address is different than your Mailing Address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Emergency Contact Name* This field is required.
First Name
Last Name
14
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
15
Emergency Contact Relationship to Applicant* This field is required.
16
Citizenship Status* This field is required.
U.S. Citizen
Permanent Resident Alien
International Student
Other
17
If you answered "Other" for your citizenship status, please explain. If you did not choose "Other" for your citizenship status, please type N/A in the text box.* This field is required.
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Which of the following best describes your high school graduation status?* This field is required.
Graduate with a Traditional High School Diploma
Graduate with a Home School High School Diploma
Recipient of a General Educational Development (GED) Certificate/Diploma
19
Have you attended any other colleges or universities?* This field is required.
YESNO
20
Name of College or University 1* This field is required.If you have not attended any other colleges or universities, please type N/A in the text box.
21
What was your major when you attended the college or university?If you have not attended any other colleges or universities, you may move on to the next question.
22
If you graduated from the college or university, what degree did you earn?If you have not attended any other colleges or universities, you may move on to the next question.
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Have you previously applied to or enrolled in any other Allied Health Program?* This field is required.These types of programs include: EMT-Basic, Athletic Training, Audiology, Cardiovascular Perfusion Technology, Certified Nursing Assistant, Cytotechnology, Dental Hygiene, Diagnostic Medical Sonography, Diagnostic Cardiovascular Sonography, Dietetics, Emergency Medical Services, Health Administration, Health Information Management, Medical Technology, Nuclear Medicine Technology, Nursing (RN or LVN), Occupational Therapy, Phlebotomy, Physical Therapy, Physician Assistant, Polysomnography, Radiation Therapy Technology, Radiography Technician, Rehabilitation Counseling, Respiratory Therapy, Respiratory Therapy Technology, Speech-Language Pathology, Surgical Technician
YESNO
24
If you answered "Yes" to the previous question, to which program(s) have you previously applied and/or been enrolled?* This field is required.Choose all that apply. If you answered "No" the previous question, please choose N/A and go to the next question.
N/A
EMT-Basic
Athletic Training
Audiology
Cardiovascular Perfusion Technology
Certified Nursing Assistant
Cytotechnology
Dental Hygiene
Diagnostic Medical Sonography
Diagnostic Cardiovascular Sonography
Dietetics
Health Administration
Health Information Management
Medical Technology
Nuclear Medicine Technology
Nursing (RN or LVN)
Nutrition Specialist
Occupational Therapy
Phlebotomy
Physical Therapy
Physician Assistant
Polysomnography
Radiation Therapy Technology
Radiography Technician
Rehabilitation Counseling
Respiratory Therapy
Respiratory Therapy Technology
Speech-Language Pathology
Surgical Technician
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What is the name of the institution(s) you were enrolled in to receive Allied Health Science education?* This field is required.If this does not apply to you, please type N/A in the text box and go to the next question.
26
Do you currently hold ANY type of healthcare certification that is regulated by a state or national entity (i.e. Texas Department of State Health Services)?* This field is required.CPR, ACLS, PALS, AMLS, ITLS, etc... are NOT healthcare certifications.
YESNO
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If you answered "Yes" to the previous question, please list the following: 1. The type of credential you hold (i.e. EMT-Basic, LVN, CNA, etc...) 2. The licensing/regulatory agency responsible for your credential 3. Your unique license/certification number 4. The issue date of the credential; and 5. The expiration date of the credential* This field is required.If this does not apply to you, please type N/A in the text box and move on to the next question.
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Copy of CertificationPlease upload a copy of your Texas EMT certification or approved Texas EMT certification application here.
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Which ACC Emergency Medical Technology Program pathway are you most interested in?* This field is required.
Advanced EMT Certificate
Paramedic Certificate
AAS Paramedic
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Are you a returning ACC Emergency Medical Technology Program student?* This field is required.
YESNO
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If you ARE a returning ACC Emergency Medical Technology Program student, when were you last enrolled in the Program?* This field is required.Please list the Semester and Year (i.e. Fall 2018). If this does not apply to you, please type N/A in the text box and move on to the next section.
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Personal Health Insurance Statement* This field is required.I understand that I must have personal health insurance to participate in the Alvin Community College (the College) Emergency Medical Technology Program (the Program). Clinical participation involves activities that may be dangerous or hazardous. I understand that participation in the Program's clinical experiences may result in injury, illness, permanent physical or mental impairment, or even death. These injuries may be minor or maybe career or life-threatening. I understand that neither the College nor the Program can be held responsible for any injuries or conditions that may be caused by the actions of patients, patient family members, patient friends, bystanders, the general public, or any other person(s) not legally associated with the College or the Program. I understand and agree that situations may arise during these activities, which may be beyond the control of the faculty and staff of the College, the Program, and their clinical and field affiliates. I release, forever discharge, and agree not to sue Alvin Community College, Board of Trustees, administrators, employees, or other participants to include the Program's clinical and field affiliates. I agree that it is my sole responsibility to be familiar with the physical and/or mental demands associated with the above-named activities. With these demands in mind, I have no physical or medical condition which, to my knowledge, would endanger myself or others if I participate in the clinical experiences offered by the Program, or would interfere with my ability to participate. I also agree to abide by any established rules or regulations while participating. I understand that there are certain inherent risks involved in participating in the clinical and field experiences required to complete this course and sit for the certification exam. I acknowledge the fact that these risks exist and I am willing to assume responsibility for any and all such risks while participating in the clinical and field experiences required to complete this course and sit for the certification exam. I understand I am solely responsible for any and all costs associated with any injury or illness that may befall me while enrolled in the Alvin Community College Emergency Medical Technology Program.
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Valid Form of Identification Statement* This field is required.I understand that I must possess one of the following forms of identification for consideration of acceptance into the Alvin Community College Emergency Medical Technology Program and to obtain any level of Emergency Medical Services certification in the state of Texas. I do hereby attest that I have one of the following acceptable forms of identification: 1. Current, valid, and non-expired Texas Driver's License 2. Current, valid, and non-expired Texas state identification card 3. Current, valid, and non-expired United States passport
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Please provide proof of a valid form of identification.* This field is required.Accepted forms of identification include a Texas-issued non-expired driver's license, a Texas-issued non-expired state identification card, or a non-expired United States passport.
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Emergency Medical Services Functional Job Description Statement* This field is required.I understand that to function as an Emergency Medical Services Professional, I must be able to adequately perform the following: 1. Verbally communicate clearly in face-to-face conversations, telephone conversations, computer (i.e. email, patient care documentation), and radio conversations. 2. Have the ability to lift, carry, and balance up to 125 pounds unassisted and 250 pounds assisted. 3.Have the ability to quickly interpret written and oral instructions. 4. Have the ability to critically think in high-stress situations. 5. Have the ability to use good judgment and remain calm in high-stress situations. 6. Have the ability to work effectively and critically in an environment with loud noises, flashing lights, and other extreme distractions. 7. Have the ability to adapt to extreme weather climates, critically think, and act in chaotic and unfamiliar environments (i.e. roadways, personal residences, and extreme outdoor circumstances) 8. Have the ability to critically think and work effectively throughout an entire shift; up to or greater than 24 hours 9. Have the ability to read and understand English language manuals and training materials, road maps, and understand dispatch instructions. 10. Have the ability to read the information on a computer screen. 11. Have the ability to discern street signs and address numbers. 12. Have the ability to interview patients, family members, friends, bystanders, and the general public with confidence, compassion, and respect. 13. Have the ability to document, on paper and electronically, relevant information with medical and legal ramifications in a prescribed format. 14. Have the ability to converse in English with coworkers and hospital staff as to patient status. 15. Have good manual dexterity with the ability to perform all tasks related to the highest quality of safety and patient care. 16. Have the ability to bend, stoop, and crawl on uneven and unfamiliar terrain. 17. Have the ability to withstand varied environmental conditions such as extreme heat, cold, and moisture. 18. Have the ability to critically and effectively work in low light, confined spaces, and other dangerous environments. 19. Have the ability to perform high-quality patient care in the back of a moving ambulance without suffering from motion sickness. 20. Have the ability to emotionally process life and death situations for patients of all types and ages. By signing below, I understand I must possess and potentially demonstrate some or all the abilities listed above to complete the course for which I am applying. I also understand that the ultimate responsibility for defining specific job descriptions lies with each individual EMS agency. I understand that even though I meet the above-listed requirements of the Alvin Community College Emergency Medical Technology Program, I am not guaranteed to meet the requirements set by every individual EMS agency employer.
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Physical Guidelines Statement* This field is required.By signing below, I attest that I read the "Physical Guidelines: In the Classroom and On the Job" form contained in the Alvin Community College Emergency Medical Technology Program Information Packet. I understand that I must possess the following functional abilities as a student in the Emergency Medical Technology Program: 1. Critical Thinking Skills 2. Interpersonal Relationship Skills 3. Effective Communication Skills 4. Effective Mobility 5. Fine and Coarse Motor Skills 6. Effective Hearing (with or without an assistive device) 7. Effective Vision (with or without corrective lenses) 8. Tactile Skills 9. Environmental Adaptation Skills 10. Excellent Concentration and Study Skills
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Criminal Background Check Statement* This field is required.All of the Program’s affiliates require that students complete and submit a criminal background check prior to being granted access to those facilities. The purpose of the Program performing criminal background screening is to comply with clinical affiliates who require student background screenings as a condition of our affiliation agreement and to promote and protect patient/client safety. Admittance into the Program is strictly prohibited for any applicant convicted of, a conviction for an attempt of, a conspiracy of, or solicitation of any of the following: 1. Murder 2. Capital Murder 3. Manslaughter 4. Criminally negligent homicide 5. Unlawful Restraint 6. Kidnapping 7. Aggravated kidnapping 8. Continuous sexual abuse of a young child or children 9. Indecent exposure 10. Indecency with a child 11. Improper relationship between an educator and student 12. Improper photography or visual recording 13. Sexual assault 14. Aggravated Assault 15. Aggravated sexual assault 16. Intentional, knowing, or reckless injury to a child, elderly individual, or disable individual 17. Intentional, knowing, or reckless, abandonment or endangerment of a child 18. Deadly conduct 19. Terroristic threat 20. Aiding suicide 21. Prohibited sexual conduct (incest) 22. Agreement to abduct a child from custody 23. Violation of certain orders in family violence case 24. Violation of protective orders in family violence case 25. Violation of protective order preventing hate crime 26. Sale or purchase of a child 27. Arson 28. Robbery 29. Aggravated Robbery 30. Burglary 31. Online solicitation of a minor 32. Money laundering 33. Medicaid/Medicare fraud 34. Cruelty to Animals 35. Compelling prostitution 36. Causing sexual performance by a child 37. Possession or promotion of child pornography 38. Any other offense for which registration as a sex offender is required Students must not have convictions in the last five (5) full years from any state or jurisdiction for any of the following: 1. Assault punishable as a Class A misdemeanor or felony 2. Theft punishable as a felony 3. Misapplication of fiduciary property of financial institution punishable as a Class A misdemeanor of felony 4. Securing execution of a document by deception punishable as a Class A misdemeanor or felony (not tampering with government record) 5. False identification as/to a peace officer 6. Disorderly conduct 7. Driving under the influence 8. Driving while intoxicated By signing below, I attest that I have a clear background and no adverse findings will appear on my background check OR I have contacted the Texas Department of State Health Services Criminal Background Review department and have received a background clearance letter from the Texas Department of State Health Services Criminal Background Review department.
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If you have received a background clearance letter from the Texas Department of State Health Services, please upload it here.If this does not apply to you, please move on to the next statement.
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Drug Screening Statement* This field is required.All of the Program’s affiliates require that students complete and submit to a drug screen prior to being granted access to those facilities. The drug screening must be completed every SEMESTER. Students who test positive for the following substances without providing a valid prescription will not be accepted into the Program: 1. Amphetamines 2. Barbiturates 3. Benzodiazepines 4. Cocaine Metabolites 5. Marijuana 6. Methadone 7. Methaqualone 8. Opiates 9. Oxycodone 10. Phencyclidine 11. Propoxyphene Alvin Community College Allied Health Programs Drug Screening Policy When the college determines that a student has a non-negative drug screen, the student is not allowed to attend any clinical rotations at any nursing and/or allied health program (including EMT) for a minimum of twelve (12) months and may affect his/her readmission to the Program. The student with a non-negative drug screen is required to withdraw from the clinical course and all concurrent health, nursing, or allied health programs. Prior to returning to the Program, the student must reapply and be accepted to the Program (including retesting), have a negative drug screen, and provide satisfactory documentation to the college and Program of successful drug counseling and treatment, all at the expense of the student. When a student with a non-negative drug screen is accepted back into the Program he/she will be subjected to mandatory unannounced random drug screening at their expense. Refusal to submit to random drug screens will result in mandatory withdrawal from the clinical course and all concurrent health, nursing, or allied health programs and reapplication will no longer be accepted. By signing below I attest that I have read and understand the understand Alvin Community College Allied Health Programs Drug Screening Policy and that I am subject to submit to drug screening at my cost as part of the application process for the Alvin Community College Emergency Medical Technology Program. I understand that the Alvin Community College Emergency Medical Technology Program requires each enrolled student to submit to mandatory drug screening each semester I am enrolled in an EMT Program clinical course (EMT-Basic, Advanced EMT, and Paramedic). I understand that the Program performs random drug screens a minimum of two (2) times per semester. I understand that I am responsible for the cost of each drug screen, including random drug screens. I understand that if I am randomly selected throughout the semester for a drug screen, I have 36 hours to complete the random drug screen. I understand that if I do not complete the random drug screen within 36 hours of being selected, I will be removed from the Program.
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Vaccination Statement* This field is required.By signing below, I understand that the Alvin Community College Emergency Medical Technology Program clinical affiliates require all Program students to provide documented proof of having received the following vaccinations or documented proof of immunity via blood titer. 1. Measles, Mumps, and Rubella 2. Varicella 3. Hepatitis B 4. Negative Tuberculosis test within the last 6 months OR negative chest x-rays (specific for TB diagnosis) within the last 6 months 5. Tetanus booster within the last 5 years 6. Meningitis for students who are 22 years old and younger 7. Flu dated between September 1st and March 31st of the year of enrollment 8. COVID for specific clinical sites; without the COVID vaccine (2 shot series only), you will not be allowed to participate in clinical experiences at the sites that require the vaccine By signing below I acknowledge that the Program clinical affiliates do not allow declinations, for any reason, for any of the above-listed vaccinations/testing. By signing below I understand that if I cannot or refuse to provide proof of immunity of the above listed communicable diseases, I will not be accepted into the Program.
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American Heart Association BLS CPR Statement* This field is required.By signing below I understand that I must obtain a current American Heart Association BLS CPR certification (2020 Guidelines). I understand that I do not have to have this certification at the time of applying to the Alvin Community College Emergency Medical Technology Program, but I do have to obtain this certification by the Wednesday of Week 3 of the semester in which I am enrolled. I understand that the Program offers the course on the second Saturday of each semester. I understand that I may obtain this certification by attending the course the Program provides or from an outside American Heart Association training site. I understand that no other forms of CPR certification will be accepted by the Program. I understand that the cost of the course the Program provides is $50.00 and is due at the time of the course. I understand that if I do not obtain an American Heart Association BLS (2020 Guidelines) CPR certification by the Wednesday of Week 3 of the semester in which I am enrolled, I will be dropped from the Program and will have to reapply to the Program during the next application window.
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