EMT STUDENT STATEMENT OF COMMITMENT

____________ Student Initials

1 of 4 Rev: 8/2004

Please Print Using Black or Blue Ink. Your Initials on Each Page, in the Space Provided, ARE REQUIRED! I, ________________ __________________ understand that I will not receive a passing First Last grade, nor will I receive my EMT certificate, nor a course completion certificate if I fail to complete any of the requirements listed below: 1. Prerequisites:

I will show proof of completing the course prerequisites by the specified due date. If I present evidence that the college prerequisite challenge form has been approved, I understand that my instructor may authorize an extension.

2. CPR Training: I will provide a copy (front and back on one side of one white 81/2” x 11” sheet of paper) of my current CPR card by the specified due date. My CPR card may be either the AHA-Health Care Provider or the ARC-CPR for Rescuers. I understand that other sources of adequate CPR training must be separately verified by my instructor and potentially may not meet the needs of the program and therefore will be denied. If my CPR class is in progress to meet this requirement, then I will submit proof of enrollment and date of completion to my instructor at which time my instructor may grant an extension.

3. Immunizations and TB Testing: I will submit proof of two Measles/Mumps/Rubella (MMR) immunizations in my lifetime, and a negative TB test within the last 6 months. I will submit this proof by the specified due date. I understand that this proof must be in the form of an official immunization record or equivalent and must bear a physician’s or RN signature to be considered valid.

4. Course Fees: I agree to pay all tuition and course fees and to show proof of payment of these fees by the by the specified due date.

5. Clinical Experience: I will submit proof of attending at least 16 hours of clinical experience divided evenly between hospital and ambulance. I understand that the clinical experience verification form and patient contact log must be completed by me, signed by hospital and ambulance staff and submitted by the specified due date.

EMT STUDENT STATEMENT OF COMMITMENT

____________ Student Initials

2 of 4 Rev: 8/2004

6. Attendance: a) I will attend all classes including mandatory Saturday classes, clinical experiences and mentorship hours on the assigned dates. b) I will miss no more than 9 total hours of class time for any reason. Tardiness and cuts will be recorded and added to my accumulative time of absence. c) I understand that three (3) tardies or three (3) cuts or combinations equal one (1) absence. d) I understand that if I miss more than 9 hours I will fall below the State mandated minimum number of contact hours and not be eligible for certification, not receive a course completion certificate and not receive a passing course grade.

7. Completion of Mandatory Classes: I will complete the three (3) mandatory Saturday classes: “MCI/HAZMAT”, “Principles of Patient Packaging and Extrication”, and the “Skills Final Examination” in their entirety. I further understand that tardiness and or cuts are not allowed on these class days. I understand that I must complete these classes on my assigned date.

8. Mentorship Program I agree to complete six (6) hours of mentorship pursuant to the guidelines as established in the mentorship presentation. I understand that this includes scheduling my mentoring hours, obtaining appropriate signatures for verification of hours, and retaining this record until the date it is due. I agree to attend my mentorship hours as I would any other mandatory class.

9. Clinical Essay/Clinical Experience Proof and Patient Contact Log and Other Class Assignments: a) I will submit the essay pertaining to my hospital and ambulance clinical experience as described by my instructor on or before the specified due date. b) I will submit my signed patient contact log and clinical experience verification forms on the specified due date. c) I will submit any other assignments on or before their specified due dates

10. Examinations and Make-ups a) I will take all examinations on the dates assigned. b) I understand that I may make up a written examination for a maximum of 50% of its original value. I understand that I will be allowed to make-up the written exam I missed within two normally scheduled class days of the missed written exam and that if more time passes I may not be eligible to make-up the written examination. I understand that make-up written exams will be given only for extenuating circumstances such as illness and that my instructor will determine my eligibility. I may be required by my instructor to provide a doctor’s note to prove my illness or show other evidence to prove the validity of the extenuating circumstance(s) which precluded me from taking my written examination. c) I understand that laboratory examinations and skills examinations may not be made up.

EMT STUDENT STATEMENT OF COMMITMENT

____________ Student Initials

3 of 4 Rev: 8/2004

11. Minimum Average Score and Skill Test Eligibility: I understand that I must achieve a minimum average score of 80% on my division examinations and mid-term skill examination and that I must attain this average score by the completion of the last division examination in order that I may be eligible to take the final skills exam.

12. Final Skill Testing: I understand that I must pass the final skills examinations according to standards developed by SRJC EMC program, and approved by the Coastal Valley EMS Agency.

13. Final Written Testing: I understand that I must pass the final written examination with a minimum of 80% AFTER having completed and having passed the final skills examinations.

14. Dress Code: I will adhere to the dress code policies of the Public Safety Training Center as outlined in the dress code memorandum at all times when in attendance of any assigned EMC program function, class, or at any time that I may be on the grounds of the Public Safety Training Center. I will adhere to the dress code policy of the EMS provider agency (ambulance clinical experience) and hospital (hospital clinical experience) where those policies supercede the PSTC policy for dress.

15. Cheating, Misconduct and Disclosure: a) I will not cheat on any examination or exercise nor will I falsify any documentation pursuant to my EMC training or mentorship experiences. I further understand that if I am caught or suspected of cheating or falsification of my documentation, that I will immediately be dismissed from class and receive a failing grade. b) I will behave professionally at all times while in attendance of an assigned school function or facility including but not limited to: class time, breaks, clinical experiences, MCI/HAZMAT, mentoring hours and patient packaging. c) I understand that I am obligated to report any misconduct or violation of SRJC/PSTC policy by my fellow students or myself to my instructor or to the EMC program director.

16. Santa Rosa Junior College and Public Safety Training Center Policies: I agree to be bound by ALL SRJC/PSTC policies and procedures for conduct, dress and facility use. Furthermore, I will not be argumentative, disruptive or disrespectful, and I will demonstrate enthusiasm. I shall be respectful of fellow students, the faculty and the staff of the SRJC/PSTC, the hospital and EMS provider agency. I will not use harsh or offensive language.

17. Failure to Meet the Terms of This Statement of Commitment: I agree to either drop, withdraw (receive a "W"), or receive a non-passing grade (whichever applies) if I am unable complete the above within the time frames listed or if I am unable to adhere to my commitment as it is written here.

EMT STUDENT STATEMENT OF COMMITMENT

____________ Student Initials

4 of 4 Rev: 8/2004

18. Appeal Policy: I understand that I have 48 hours from the time of an alleged infraction to appeal the action taken against me. All appeals must be in writing and addressed to the associate Dean of Public Safety at the Public Safety Training Center.

19. Understanding, Duration of Commitment and Affirmation: I fully understand and agree to be bound by this statement of commitment in its entirety for the duration of my enrollment in EMC 274. My signature below is my affirmation of this intent.

Signature: _____________________________________ Date _________ Print Name: ____________________________________________