Ron GUI NREMT TRAINING OFFICER / Submitted:
TheAustralasianRegistryOfEmergencyMedicalTechnicians
ParamedicRegistrationForm2018
Name / Date of
Birth / Registry
Number
Mailing / PhoneNumber / Email
Payment / Payment
Amount / PaymentStatus
Employer / Employer
Address / EmployerPhone
Number
Certifications
CPR / ACLS
AstheEMSProfessional'sCPRInstructor/TrainingOfficer,Ihereby
verifytheEMSProfessionalhasbeenexaminedandperformed
satisfactorilysoastobedeemedcompetentineachofthefollowing:
•Adult12RescuerCPR
•AdultObstructedAirway
•ChildCPR
•ChildObstructedAirway
•InfantCPR
•InfantObstructedAirway
VerifyingSignature:
______
Submitcopyofcardand/orverifywithappropriatesignature
EMT'sCPRExpirationDate: / ExpirationDate:
Submitacopyofcard.
VerificationOfSkillCompetence
Q/A:Q/I / DirectObservation / Other
PatientAssessment/Management / • / MedicalandTrauma
VentilatoryManagementSkills/Knowledge / • / Simpleadjuncts
• / Supplementaloxygendelivery
• / Supraglotticairways(PTL,Combi-tube,
ET)
• / EndotrachealIntubation(adultpediatric)
• / ChestDecompression
• / TranstrachealJet
Ventilation/Cricothyrotomy
Professional Statement / AREMT Status
If you have not already completed Privacy
Verification document, PLEASE see attached
Sinceyourlast/initialcertification,haveyoubeensubjectto
limitation,probation,suspension,orrevocationofyourright
topracticeinahealthcareoccupationorvoluntarily
surrenderedahealthcarelicenseinanystateortoany
agencyauthorizingthelegalrighttowork?
2018.AREMT.registration
ParamedicContinuingEducation(48HoursRequired)CourseName / Sponsor/Provider / Date
Completed / Methodof
Instruction / Hours
Received
(Paramedic Initial Training(1020HoursRequired Including EMT)
TopicsofTraining / Hours
Required / CourseName / Sponsor / Date
Completed / Methodof
Instruction / Hours
Received
1020 / 1020
**Content may be separate attachment / TotalHours / 1020
SubmitCourseCompletionCertificateofstateapprovedAREMTNationalStandardParamedicor equivalent programcompletedwithin
This registrationcycle.
AND
SubmitanOfficialLetterfromyourEmployer/TrainingOfficerorMedicalDirectorverifyingcompletionofallmandatoryandflexiblecore
contentincludingcompletiondatesandhoursandmethodsused.
VerificationOfSkillCompetence
Q/A:Q/I / DirectObservation / Other
CardiacArrestManagement / • / MegacodeECGRecognition
• / Therapeuticmodalities
• / Monitor/Defibrillatorknowledge(set-up,
routinemaintenance,pacing)
HemorrhageControlSplintingProcedures / Verification of competency
IVTherapyIOTherapy / • / MedicationAdministration
SpinalImmobilization / • / Seatedlyingpatients
OB/GynecologicSkills/Knowledge / Verification of competency
OtherRelatedSkills/Knowledge / • / Radiocommunications
• / Reportwritingdocumentation
2018.AREMT.registration
AsPhysicianMedicalDirector/Training ManagerofParamedictraining/operations,Idoherebyaffixmysignatureattestingtocontinuedcompetenceinallskills
outlinedabove.
______/ ______/ ______
PhysicianMedicalDirectorSignature(mustbeoriginal
signature) / Title / DateSigned
IherebyaffirmthatallstatementsontheParamedicregistrationFormaretrueandcorrect,includingthecopiesofcards,certificatesand
AREMTParamediccourseattachment.ItisunderstoodthatfalsestatementsordocumentsmaybesufficientcauseforrevocationbyAREMT.
ItisalsounderstoodthatAREMTmayconductanauditofthecertificationactivitieslistedatanytime.
______/ ______
YoursignatureDatesigned / SignatureofTrainingOfficer/Supervisor
(mustbeotherthanEMSProfessional
mustbeanoriginalsignature) / DateSigned
DEBIT MY CREDIT CARD ($150.00 INCLUSIVE OF GST, 1.5% ON-LINE MERCHANT FEE (PLUS Amex & Paypal 3.5%, trackeable Post $15 in Australia OR $30 Overseas )
Card InformationCARD TYPE >VisaMasterCardAmerican ExpressBankard
CARD NUMBEREXPIRATION
MMYYYYLAST THREE (3) DIGITS ON THE BACK OF THE CARD
SIGNATURE
MMDDYYYY
OVERSEAS BANK TRANSFER TO: AUSTRALASIAN REGISTRY OF EMERGENCY MEDICAL TECHNICIANS
SWIFT CODE > Metwau4b ACCOUNT NUMBER >O27555O75 BSB >484-799
BANK> Suncorp Metway Brisbane
PAY ONLINE USING PAYPAL. UNDER "REGISTRATION" PAGE. EXCLUDES trackeable postage fee …A$150.00
AustralasianRegistryofEmergencyMedicalTechnicians
POBox3007
West Ipswich Queensland 4305 AUSTRALIA
(617)32815654
EMAIL:
ParamedicContinuingEducation
CourseName / Sponsor / Date
Completed / Methodof
Instruction / Hours
Received
*Someorallofthiscourse'shourswerenotcountedtowardsthistopic,becauseoneormoreearlier
courseshavealreadyfulfilledtherequirednumberofhours. / TotalHours / 24
2018.AREMT.registration