Dodge County Paramedic Enrollment Application

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Student Information

Information Do ID-compliant

Name

First

Middle

Last

Mobile Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Last 4 of SSN

Only last 4 digits required. Full SSN will be collected later.

EMT License Number

State or NREMT

Polo / T-Shirt Size

Emergency Contact Information (Required)

Provide the name and contact information for the person we should contact in case of an emergency during training or clinical rotations.

Emergency Contact

Name

Relationship

Phone

Alternate Phone

Eligibility & Compliance Confirmation (Required)

I have a High School Diploma or GED
I will be at least 18 years old by course completion
I have a US Drivers License in good standing
I am a US Citizen (Real ID)
I understand that the Student Handbook and full program policies will be provided upon acceptance and prior to the start of the course, and I agree to review and comply with those requirements.

Have you EVER been convicted of a felony or serious misdemeanor?

Drug Screening & Background Compliance

I understand that I may be required to undergo a criminal background check and drug screening as a condition of clinical placement and licensure, and that results may impact my eligibility to participate in clinical rotations, complete the program, or obtain certification and employment.

Identification & Required Documents (Required)

Please upload the required documents below. Clear, legible images or PDFs are required for processing your application.

Driver’s License (Front and Back)

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Upload a clear photo or PDF of your valid government-issued driver’s license.

Your driver’s license should be a Real ID-compliant license, indicated by a gold or black star.

Your driver’s license should be a Real ID-compliant license, indicated by a gold or black star.

Additional documentation will be required prior to clinical rotations and program start. These may include, but are not limited to:

Proof of EMT certification/license

* Proof of High School Diploma or GED
• Immunization and vaccination records
• Drug screening and background check clearance

• Proof of Health/accident insurance
• Physician’s statement verifying fitness for duty

Detailed instructions will be provided upon acceptance.

Document Requirements Acknowledgement

I understand that additional documentation will be required prior to program start and agree to provide all required materials as instructed.

Required Agreements & Acknowledgements

The following statements are required acknowledgements. Each must be reviewed and accepted before submission of this application.

Authorization

I authorize Rescue Training Inc to contact employers and educational organizations regarding my employment and education. I authorize my employers and educational organizations to fully and freely communicate information regarding my employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my employment and education.

Substance / Drug Abuse Policy

I certify that I am not currently using any illegal drugs or controlled substances. I understand that I must not use any illegal drugs or controlled substances during my enrollment in the course, and that I must not consume alcohol prior to attending class, participating in skills activities, or reporting to any clinical rotation. I understand that failure to comply with this requirement may result in disciplinary action, removal from clinical participation, and/or dismissal from the course.

I further understand that drug screening or additional documentation may be required as part of program, clinical site, or regulatory compliance requirements.

Felony Statement

By signing below, I am stating that I have never committed, nor been charged with, nor being investigated for, nor prosecuted for any felony offense in the state of Georgia or any other state. I fully understand that my failure to disclose this information regarding a felony record or investigation my result in my dismissal from the Program or denial by the Georgia State Office of EMS & Trauma to issue a license or certification. I fully understand that to attend the program with a felony offense or on-going investigation that I am required to obtain permission from the Georgia State Office of EMS & Trauma. Any felony offense should be immediately brought to the attention of the EMS Program Director, so as to forward such information to the Georgia State Office of EMS & Trauma for consideration of possible permission to attend the EMS Program.

Cancellation and Refund Policy

Should a student's enrollment be terminated or cancelled for any reason, all refunds will be made per the following refund schedule: • Cancellation notification must be made in writing, by electronic mail, letter, or by certified mail. • All monies will be refunded if the school does not accept the applicant or if the student cancels within three (3) business days after signing the enrollment agreement and making initial payment. • Cancellation after the third (3rd) business day, but before the first class, will result in a refund of all monies paid, except for the registration fee, not to exceed $150.00. • Cancellation after attendance has begun, but prior to 50% completion of the program, will result in a refund for the number of and amount of any prepaid months (no refund for the current month). • Cancellation after completing 50% of the program will result in no refund. When calculating the refund due to a student, the first month of actual non-attendance during the month by the student (after written notice has been given) is used to determine the prepaid month or months due a refund. Refunds will be made within 30 days of termination of the student’s enrollment or receipt of a Cancellation Notice from the student.

Hold Harmless / Negligence

In consideration for working in the EMS field, Rescue Training Inc provides me the opportunity to acquire training and instruction, I, the undersigned, agree to indemnify, protect, and hold harmless Rescue Training, Inc., and its officers, directors, employees agents and assignees, from any and all liability judgments, claims, costs, damages, or injury arising out of or in connection with any and all acts of negligent conduct on the part of the undersigned, however caused, during any instructional, clinical, or training activity. I agree that I will defend, at my own expense, all actions, lawsuits, or proceedings which may be brought against Rescue Training Inc in connection with the above and shall satisfy, pay, and discharge any and all judgments that may be entered against RTI, the Hospital, or EMS Agency in any such actions or proceedings.

Health / Accident Insurance

Each student must provide proof of health/accident insurance coverage at the beginning of the course or sign a notarized waiver of health insurance coverage. Rescue Training Inc, Southeast GA EMS, Region IX, GA Dept of Public Health, State Office of EMS & Trauma, and any clinical facility is not responsible for any injury, illness, or health care costs that may be incurred or associated with any practice, skills, clinicals, or any other training provided by Rescue Training Inc.

Payment Responsibility

Please tell us who will be responsible for tuition and enrollment payment. Your seat is not guaranteed until payment, payment plan setup, agency sponsorship approval, or VA eligibility verification is completed.

Payment Responsibility

Self Pay — I am responsible for my tuition/payment plan.
Agency Sponsored — My agency will be responsible for payment.
VA Student — I will be using VA education benefits.

Enrollment Acknowledgements

I understand my seat is not guaranteed until payment, payment plan setup, agency sponsorship approval, or VA eligibility verification is completed.

Do you agree to use digital signature?

Digital Signature (Required)

By typing your full name above, you agree that this electronic signature is the legal equivalent of your handwritten signature under applicable electronic signature laws (including ESIGN and UETA). You certify that all information provided is true and complete and that you agree to all policies, terms, and conditions of Rescue Training Inc. You understand that falsification of information may result in denial of enrollment or dismissal from the program.

Application Date

--- internal use only ---

Security Notice: This secure application is used only for enrollment, student records, and required program compliance. Uploaded documents are sent to Rescue Training Inc. for administrative review and are not shared except as required for course, clinical, or regulatory purposes.

Student Information

Emergency Contact Information (Required)

Emergency Contact

Identification & Required Documents (Required)

Required Agreements & Acknowledgements

Payment Responsibility

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