You are responsible for the content and timely completion of this application.

Manatee Technical Institute’s EMS programs are accredited by the National Committee on Accreditation of Educational Programs for the Emergency Medical Service Profession (CoAEMSP) and the State Bureau of Emergency Medical Services of Florida Department of Health

Additional Information:

  • Make copies of all of the required application items and keep your originals. We cannot make copies for you.
  • All MTIEMS students will be given a drug test during their program. A positive drug test will result in immediate withdrawal from the program without a refund.

Check-Off List

1. ______MTI Application ______Student Consent Form

2. ______Copy of an unofficial Transcript showing the date that the diploma /

GED was received (you may also include a copy of the actual - high

school diploma / GED certificate)

3. ______Copy of Driver’s License

4. ______FL Residency form with copies of 2 documents attached.

5. ______Background Investigation: (Level 2 - Fingerprinting)– (office)______

6. ______TABE Scores *______or AS degree or higher

Reading______Total Math ______Language ______

Date ______

7. ______Physical Exam Date ______

8. ______Immunization Dates – need copies of shot records

1. MMR Dates 1st______2nd ______

-OR- Positive Titer Date ______

2. Tdap - within last 10 years ______

3. PPD (Tuberculosis Skin Test) 1st (anytime) ______

2nd (within 12 mths of start date) ______

-OR- X-Ray ______

4. Varicella (Chicken Pox) 1st ______2nd ______

-OR- Positive Titer Date ______

5. Hepatitis B 1st ______2nd ______3rd ______

-OR- Positive Titer Date ______

-OR- Signed Declination______

9. ______Letter of Intent (500 words or less – typed)

_____*Self-Addressed Stamped Envelope- for Letter of Acceptance & Registration Information .

10. Paramedic Only ____ CPR – Expiration Date ______

____ Copy of EMT Certificate

____ Documented 250 hours in EMS Field

____ Oral Interview

Application Form

EMT-B  Paramedic 

EMT-Basic & Paramedic Day ____ or Night____

Emergency Medical Services Programs

Manatee Technical Institute

Instructions: Read through the application process before filing this out. Please answer all questions completely, accurately and truthfully. If an item does not pertain to you, please answer “N/A” (not applicable). Keep in mind that all information will be checked and verified. Misstatements, falsification or omissions may delay entrance into the Emergency Medical Services Program. Please print legibly. Your application cannot be completely processed if the information is not legible.

Today’s Date: ______/______/______

Exact Legal Name (Please Print)

______

Last NameFirst NameMiddle NameMaiden Name

Social Security # _____-_____-______Student ID #: ______Date of Birth: ___/___/___

Permanent Address (Residence):______

City: ______State: ____Zip Code:______County: ______

Current Mailing Address: ______

City: ______State: ___ Zip Code: ______County: ______

Home Phone: ______Work Phone: ______

E-Mail: ______Cell Phone: ______

Emergency Contact: ______

Relationship: ______Phone: ______

Gender: Male  Female Race: African-American  Asian Caucasian Hispanic  Other: ______

Country of Birth: United States of America Other ______

Are you a U.S.Citizen? Yes  No  If Naturalized, what is your number? ______

Are you Florida Residence? Yes  No  If No, what state? ______

Do you possess a valid Driver’s License? Yes  No 

Driver’s License Number: ______State Issued: ___Expiration Date: ______

Arrest History

If you answer yes to any of the following questions, please explain. You may need to provide copies of any relevant paperwork (reports, release papers, etc.) Attach a separate sheet of paper if you need more space.

Have you ever been arrested (adult or juvenile)?YesNo

Have you ever been arrested for a felony charge?YesNo

Have you ever been arrested for a drug or alcohol violation?YesNo

Have you ever been convicted of any charges?Yes No

Have you ever been issued a traffic citation?YesNo

If you answered YES to any questions, please explain/describe:

______

______

______

______

______

______

Failure to provide true and accurate statements will result in your application being disqualified for consideration.

School History

Please provide information for all school attended, beginning with High School/GED.

1. High School: ______City/State ______

Diploma Received: ______Date of Attendance: ______

2. School: ______City/State ______

Diploma Received: ______Date of Attendance: ______

Number of Credits Completed: ______

3. School: ______City/State ______

Diploma Received: ______Date of Attendance: ______

Number of Credits Completed: ______

4. School: ______City/State ______

Diploma Received: ______Date of Attendance: ______

Number of Credits Completed: ______

Employment History

Beginning with present employment, list your three most recent employers, including summer and part-time work while attending school. Addresses must be complete.

1. Dates of Employment: From: ______To: ______

Month/YearMonth/Year

Name of Company: ______

Street Address: ______

City, State, Zip Code: ______

Telephone: ______Supervisor: ______

Position held and duties: ______

______

______

2. Dates of Employment: From: ______To: ______

Month/Year Month/Year

Name of Company: ______

Street Address: ______

City, State, Zip code: ______

Telephone: ______Supervisor: ______

Position held and duties: ______

______

______

3. Dates of Employment: From: ______To: ______

Month/YearMonth/Year

Name of Company: ______

Street Address: ______

City, State, Zip code: ______

Telephone: ______Supervisor: ______

Position held and duties: ______

______

______

Specialized Training, Experience & Coursework

Please include a copy of your transcript and copies of any relevant certifications with this application. You will be given credit for training and course-work that can be verified with a valid certificate or a transcript.

Provide dates, institution/agency and city for any that applies to you:

CPR Training: ______

First Responder (40hr): ______

Anatomy & Physiology: ______

Medical Terminology: ______

First Aid: ______

FireSchool: ______

Additional Fire: ______

Fire Volunteer: ______

Hospital Employment: ______

Hospital Volunteer: ______

Law Enforcement: ______

Military Training: ______

Other: ______

______

______

(If there is further experience not yet mentioned that you would like included in your application, please add on a separate piece of paper or attach a resume/CV)

Paramedic Applicants:

Do you have a valid and current State of Florida EMT certificate?YesNo

Certificate Number: ______

Have you completed a college level course in Anatomy and Physiology?YesNo

When and where did you complete it? ______

Have you completed a college level course in Medical Terminology?YesNo

When and where did you complete it? ______

EMS Programs

STUDENT CONSENT FORM

As a student enrolled in a Manatee Technical Institute EMS Program, I understand that the required clinical experiences in various health care arenas may expose me to environmental hazards and infectious diseases including, but not limited to, tuberculosis, hepatitis B and HIV (AIDS).

Neither Manatee Technical Institute nor any of the clinical or internship organizations used for clinical or internship experience assumes liability if a student is injured or exposed to infectious disease in the clinical facility or EMS unit during assigned clinical or internship experiences, unless the injury/exposure is a direct result of negligence by Manatee Technical Institute or the clinical or internship organization. As a student, I understand that I am responsible for the cost of health care for any personal injury/illness that occurs during my education. Manatee Technical Institute strongly recommends that students purchase their own health insurance.

Every EMS student is required to carry liability insurance while enrolled in clinical courses. This insurance is automatically purchased by the Manatee County School Board.

I also understand my responsibility to strictly maintain the confidentiality of all client information, whether personal or medical, as well as keep confidential any information related to the clinical facility. As an EMS student, I clearly understand and fully agree, under the penalty of law, that I will never inappropriately access, disclose or reveal in any way, either directly or indirectly, any information from a client’s record or related to the care and treatment of any client, except, as needed, to authorized clinical staff. I further agree not to reveal any confidential information about the clinical facility to any third person.

Each student also is responsible for adhering to the policies and procedures of the Manatee Technical InstituteEMS Program as well as Manatee Technical Institute as noted in the student handbooks.

My signature on this form confirms that I understand and assume responsibility for the inherent risks involved in being a student in an EMS Program at Manatee Technical Institute, and for adhering to the above policies.

______-______-______

Student Name (please print) Student’s SS#

______

Student’s Signature Date

______

Parent/Guardian Name if minor Parent/Guardian Phone #

______

Parent’s Signature (if minor or in high school) Date

Florida Residency Classification

To receive in-state tuition rates, students must prove that they have maintained Florida residency for at least 12 complete months prior to their first day of school. (See approved documents listed on back).

Dependent or Independent Student? Please check the appropriate classification

_____ I am an independent person and have maintained legal residence in Florida for at least 12 months.

A student who meets any of the of following criteria shall be classified as an independent student for the determination of

residency for tuition purposes:

  1. The student is 24 years of age or older by the first day of classes of the term for which residency status is sought at a Florida institution;
  2. The student is married;
  3. The student has children who receive more than half of their support from the student;
  4. The student has other dependents who live with and receive more than half of their support from the student;
  5. The student is a veteran of the United States Armed Forces or is currently serving on active duty in the United States Armed Forces for purposes other than training;
  6. Both of the student’s parents are deceased or the student is or was (until age 18) a ward/dependent of the court;
  7. The student is working on a master’s or doctoral degree during the term for which residency status is sought; or
  8. The student is classified as an independent by the financial aid office at the institution.

Applicants under age 24 can claim independence with proof of acceptable income and based on strict guidelines from Florida Statues. See:

_____ I am a dependent person and my parent or legal guardian has maintained legal residence in Florida

for at least 12 months.

_____ I am a dependent person who has resided for five years with an adult relative other than my parent or legal guardian, and my relative has maintained legal residence in Florida for at least 12 months. (Required: A copy of most recent tax return on which you were claimed as a dependent or other proof of dependency).

_____ I am married to a person who has maintained legal residence in Florida for at least 12 months. I have now established legal residence and intend to make Florida my permanent home. (Required: A copy of marriage certificate, claimant’s voter registration, driver’s license and vehicle registration).

Residence in Florida must be as a bonafide domicile rather than for the purpose of maintaining a residence incident to enrollment at an institution of higher education. To qualify as a Florida resident, you must be a U.S. Citizen or an eligible non-citizen. Living in or attending school in Florida will not, in itself, establish legal residence. Students who depend on out-of-state parents for support are presumed to be legal residents of the same state as their parents.

Person claiming Florida Residency must complete this section and sign.

If student is a dependent, documents and signature must be from a parent/guardian.

Include photocopies of two documents from approved list on back.

Name of student ______

Name of person claiming FL residency ______Relationship to student______

I do hereby swear or affirm that the above named student meets all requirements indicated in the checked category above for classification as a Florida resident for tuition purposes. I understand that a false statement in this affidavit will subject me to penalties for making a false statement pursuant to 837.06, Florida Statues, and to Rule 6C-7.005 F.A.C.

Signature of person claiming FL Residency ______Date ______

In-State Tuition for MTI Students

State statutes require that all adult students who attend MTI pay for tuition rates based on whether or not the student, or parent/guardian for a dependent student, has resided in Florida for the past 12 months.

What is Proof of Residency?

Two documents are required. At least one (1) must be from First Tier; the second document may also be from First Tier or may be from Second Tier.

First Tier

  • Florida Driver license or State of Florida identification card
  • Florida voter registration card
  • Florida vehicle registration
  • Proof of purchase of a permanent home in Florida that is occupied as a primary residence of the claimant
  • Transcripts from a Florida high school for multiple years if Florida high school diploma or GED was earned within last 12 months
  • Proof of permanent full-time employment in Florida (one or more jobs for at least 30 hours per week for a 12-month period)

Second Tier

  • A Florida professional or occupational license
  • Florida incorporation
  • Documents evidencing family ties in Florida
  • Proof of membership in Florida-based charitable or professional organizations
  • Utility bills and proof of 12 consecutive months of payments
  • Lease agreement and proof of 12 consecutive months of payments
  • State or court documents evidencing legal ties to Florida
  • Benefit histories from Florida agencies or public assistance programs
  • Declaration of domicile in Florida (12 months from the date the document was sworn and subscribed as noted by the Clerk of Circuit Court)

Unacceptable Documents that May NOT be Used

  • Hunting or fishing licenses
  • Library cards
  • Shopping club/rental cards
  • Birth certificate
  • Passport
  • Social Security Card

When applying please bring copies of your documents.

MANATEE TECHNICAL INSTITUTE

HEALTH PROGRAMS

PRE-ENTRANCE PHYSICAL EXAMINATION

This section to be completed and signed by applicant before examination and reviewed with physician.

Name ______Phone ______

Address______Street No. or P.O. Box City State Zip Code

Medical History: Do you now have or have you ever had any of the following:

Condition ………… / Yes / No / Condition ………… / Yes / No / Condition ………… / Yes / No
Asthma / Epilepsy / Tuberculosis
Alcoholism / Fainting Spells / Varicose veins
Arthritis / Heart condition / High Blood Pressure
Back Trouble / Hepatitis / Severe Headaches
Drug dependency/
Addiction / Hypertension / Emotional/Psychiatric
Disturbance
Diabetes / Kidney disease
If you answered “Yes” to any of the above, please give details ______

______

List any allergies______

Have you had any serious injuries or operations? ______

List with approximate dates______

List any medications taken regularly: ______

In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired practitioner program ______Yes ______No

If Yes, please explain:

______

In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder or impairment? ____Yes ___No If yes, please explain:

______

In the last 5 years have you been treated for or had a recurrence of a diagnosed physical impairment?

___Yes ___No If yes, please explain: ______

______

In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive disorder?

____Yes ___No If yes, Please explain: ______

______

Student/Applicant Signature: ______

Applicant Name: ______

Hgt ______Wgt ______Blood Pressure______Temp.______Pulse______Resp.______

Visual Acuity: Right with / without corrective lenses ______/______

Left with / without corrective lenses ______/______

Are there any abnormalities of the following systems? Describe fully on separate sheet and attach

System ……………………… / No… / Yes.. / Comments………………………………………………………………
1. Respiratory
2. Cardiovascular
3. Gastrointestinal
4. Hernia
5. Eyes/Ears
6. Genitourinary
7. Musculoskeletal
8. Metabolic/Endocrine
9. Neuropsychiatric
10. Skin

Name of examiner: ______Phone Number: ______

Address: ______City: ______State: ___ Zip: ______

Signature of examiner: ______Date of exam______

Physician or Nurse Practitioner

Immunizations……………… / Date ……… / Given or Results .. / Signature of Doctor or Nurse
Measles/Mumps/Rubella / ______/ ______/ ______
1st MMR
2nd MMR
Or Positive Titer (for all 3) with lab report
______/ ______/ ______
Tdap-Tetanus/Diphtheria/Pertussis (within last 10 yrs)
PPD/ Tuberculosis skin tests for health care providers / ______/ ______/ ______
#1
#2
OR Quantiferon Gold in tube test
ORstatement of negative chest x-ray within 2 years and statement of “no current symptoms”
Varicella (Chicken pox) / ______/ ______/ ______
1st varicella
2nd varicella
OR positive titer with Lab report
Hepatitis B (strongly recommended)

NOTE:The Hepatitis B vaccine is highly recommended for the profession for which you are training. Clinical/field internships may expose you to carriers of the Hepatitis B strain.

PROOF OF IMMUNITY:

1)Documentation of immunization will consist of a written dated statement by a physician on this form or on his/her stationary that specifies the date seen and states that the person has had the specific vaccines listed above. All immunizations are required regardless of age.

2)Laboratory (serology) evidence of measles, mumps, rubella and chicken pox immunity would be acceptable Lab report required