Financial Aid Agreement for EMT Training I, ______________________________ understand the North Fork Ambulance will pay for my tuition (including books, and associated fees) as an enrolled student in the EMT-Basic course through the Delta-Montrose Technical College (DMTC), only if ALL of the following requirements are met.

Within three (3) months of the date of the EMT Class Written Exam, I must:

1. Pass the written final exam for the EMT course, obtain a passing score on all practical examinations, and meet all requirements for the course as defined by the DMTC and instructor.

2. Complete all necessary clinical hour rotations at an approved Emergency Department and Ambulance Service to obtain my necessary patient contacts in order to register for the National Registry Exam.

3. Pass the National Registry Exam.

4. Obtain a State of Colorado EMT Certification as soon as possible, following attainment of National Registry Certification.

5. Complete Initial Training as Outlined in the Association’s Policy book.

6. Agree to meet the minimum personnel standards as outlined in the NFAA Personnel Minimum Standards (NFAA Policy 2) for a period of at least one (1) calendar year from the date of my initial State of Colorado EMT-B Certification.

[ ] I acknowledge by checking this box, that I have read, fully understand and agree to abide by the Personnel Standards defined in the Association Policy #2.

If any of these conditions are not satisfied, I understand that I am personally responsible for the full-amount of the EMT course tuition, including books & associated fees, which were paid by the Association. I understand that I will receive a bill, payable within 30 days if these conditions are not satisfied. After 30 days, I understand the outstanding balance will accrue interest at the current prime rate. I further understand all outstanding bills will be turned over to a collection agency for collection of payment.

I understand the Board of Directors of the North Fork Ambulance Association may grant an extension of this agreement for extreme hardship or circumstances beyond my control. If difficulties arise before I obtain my State of Colorado certification, I must present the Board with documentation/explanation of my hardship prior to the three-month deadline identified below. If a difficulty shall arise after obtaining my State of Colorado certification, I must present the Board with documentation/explanation of my hardship prior to the conclusion of the one-year commitment period.

I understand, that if I pay for my EMT course tuition (including books & associated fees) I may later apply for reimbursement of that tuition from the Association, upon satisfying requirements one through six above.

_______________________________________________ ______________________________ EMT Course Student/Applicant Signature Date _______________________________________________ _______________________________ Board Member Signature Date

For Board Use Only:

Approximate Date of EMT-B Written Exam: Approximate Three-Month Deadline:

Actual Date of Course Written Exam: Cost of Tuition (including Books & Associated Fees) for Course: $

Three-Month Deadline Date: Completed? Date of Completion: Billed?

One-Year Period of Service Conclusion Date: Completed? Date of Completion: Billed?