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MINERAL AREA COLLEGE PARAMEDIC TECHNOLOGY

 Dear Applicant:

Please submit this application form by May 31, 2018.

Your file must contain the following before your application can be submitted to the Selection Committee for final selection. All documents must be official (sent to Mineral Area College by the Institution). Hand carried transcripts will not be accepted.

  1. Apply for admission to MAC. This may be done online at www.mineralarea.edu -->Admissions-->online application. Submit your high school transcript. (Current high school students must submit transcripts to date, followed by one final transcript in May. Request one to be sent to the Allied Health Dept/Attention Mrs. Ross, P.O. Box 1000, Park Hills, MO 63601. Note: this is not necessary if you are a current MAC student.
  2. GED scores (if applicable).
  3. American College Test (ACT) scores or ACCUPLACER scores will also be accepted.
  4. Achieve 75% or above on the Paramedic Entrance Exam. This test may be repeated once only. Exams are completed by scheduling with Mrs. Zuellig at azuellig@MineralArea.edu.
  5. Previous college transcripts (if applicable). Please request an official copy to be sent to the Allied Health Dept/Attention Mrs. Ross, P.O. Box 1000, Park Hills, MO 63601. Note: this is not necessary if you are a current MAC student.
  6. Previous professional school transcripts (if applicable).
  7. Please note the pre-requisite courses and deadlines for completion as indicated in the program brochure.
  8. Typed answers to questions (see application).
  9. The applicant is responsible for checking that reference form letters and the above required documents have been returned to the Allied Health Department/Attention Mrs. Ross.
  10. There is a $20.00 application fee made payable to Mineral Area College due when your application is submitted online payable by credit card only.  If you would like to pay by other method, please print the application and return the application with payment (cash or check) in person or via mail.
  11. Information for references must be filled out completely: name, street, city, state, and zip code. Incomplete addresses will not be processed. A College form letter will be sent to each reference listed on the application. There is no need to ask for a letter of reference.
  12. Please be sure all paperwork for financial aid is submitted and your FAFSA application is completed online. Questions regarding financial aid should be referred to the Mineral Area College Financial Aid Department (573)518-2133.
  13. Students accepted into the Paramedic Technology program will be required to pass a drug screen/criminal background check to continue in the program. This will be completed on the mandatory orientation day.

FAILURE TO FOLLOW THESE INSTRUCTIONS MAY PREVENT YOUR APPLICATION FROM BEING CONSIDERED FOR PROGRAM SELECTION.

I agree that I have read and that I understand the information listed above.  I have also read and I understand the brochure:

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Date:

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APPLICATION FOR ADMISSION

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First name:

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Middle name:

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Last name:

 

Maiden Name:

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Street:

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City, State, Zip Code:

 

Cell Phone Number:

 

Home Phone Number:

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Email:

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Date of Birth:

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MAC Student ID Number:

 

Other Last Names:

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NOTE: Have you ever been convicted, adjudged guilty by a court, pled guilty or pled nolo contendere to any crime (excluding traffic violations), whether or not sentence was imposed?

If yes, explain fully. FBI and Highway Patrol background checks are required for licensure.

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EDUCATIONAL BACKGROUND

 

Elementary Algebra or above for College Credit Grade:

 

Year:

 

Introductory Chemistry for College Credit Grade:

 

Year:

 

English Composition for College Credit Grade:

 

Year:

 

Medical Terminology Grade:

 

Year:

 

Anatomy & Physiology for Paramedics Grade:

 

Year:

 

Anatomy for College Credit Grade:

 

Year:

 

Physiology for College Credit Grade:

 

Year:

 

Combined Anatomy & Physiology Grade:

 

Year:

Only college level Medical Terminology and a college level Anatomy/Physiology course is required (see brochure for more information). Note: if you are currently enrolled in any of these classes at the time of this application, write "in process" in the grade area.

 

High School Name:

 

Location (City):

 

State:

 

Date of Graduation:

 

EMT class completed at:

 

GED:

 

Date:

College(s) Attended & Year (include MAC and any college where you have earned dual college credit):

 

Have you ever been a student in any paramedic program:

 

Year:

 

If so, where?

 

Diploma:

Reason for not completing:

The American College Test (ACT) or the ACCUPLACER is required prior to admission. Scores must be filed in the Allied Health Department prior to Selection. Application deadline is May 31, 2018.

High School transcripts, GED scores, college transcripts and this application must be filed with the college as soon as possible. Send these immediately to: Mineral Area College, Attn: Allied Health Department, P.O. Box 1000, Park Hills, MO 63601.

Non-Discrimination Policy - Mineral Area College is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, gender, gender identity, disability, age, religion, creed,  marital or parental status, or genetic and family medical history as defined by GINA, in admissions/access to, or treatment/employment in its programs and activities. For more information, call the Title VI,Title IX,Sec. 504 and ADA coordinator at (573) 431-4593 or U.S. Dept. of Education, Office of Civil Rights.

ADA Policy - If you have special needs as addressed by the Americans with Disabilities Act and need this publication in an alternative format, notify Mineral Area College, (573) 431-4593 or P.O. Box 1000, Park Hills, MO 63601, at least one week before you plan to attend events or meetings. Reasonable efforts will be made to accommodate your special needs.

Tobacco-Free Policy - For the health of our community, Mineral Area College properties are TOBACCO-FREE indoors and outdoors. For more information the tobacco-free policy, please visit http://www.mineralarea.edu/generalinformation/TobaccoFree/TobaccoFreePolicy.aspx.

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WORK EXPERIENCE

List employment beginning with most recent: Specifically include: (1) Present employer; (2) Any health care related employer, present or past. (3) Teacher, administrator, or past employer. Do not include relatives or clergy. A College form letter will be sent to all references. Incomplete addresses will not be processed.

NOTE: Please do not use the same person's name twice. For example: Do not use Bob Jones as an employment reference and a personal reference. It is acceptable to use two different individuals at the same place of employment.

 

 

Name of Employer:

 

ATTN first name:

 

ATTN last name:

 

Address:

 

City, State, Zip Code:

 

Position Held:

 

Start date:

 

End date:

 
  
 

Name of Employer:

 

ATTN first name:

 

ATTN last name:

 

Address:

 

City, State, Zip Code:

 

Position Held:

 

Start date:

 

End date:

  
 

Name of Employer:

 

ATTN first name:

 

ATTN: last name:

 

Address:

 

City, State, Zip Code:

 

Position Held:

 

Start date:

 

End date:

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PERSONAL REFERENCE

Please list two personal references (do not include relatives or clergy).

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First name:

 

Last name:

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Street:

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City, State, Zip Code:

  
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First name:

 

Last name:

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Street:

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City, State, Zip Code:

REFERENCE LETTER RELEASE FORM

In applying for admission to the Paramedic Technology Program at Mineral Area College, I hereby voluntarily waive my right to access as provided by Federal Law, PL93-380, to confidential letters and statements of recommendation submitted by references on my behalf. I request that persons listed as my work and/or personal references release information to Mineral Area College.

 

I agree that I have read and and that I understand the Reference Letter Release information listed above. 

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Date:

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MINERAL AREA COLLEGE HEALTH INVENTORY FORM

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Name:

 

Maiden Name:

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Street:

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City, State, Zip Code:

 

Cell Phone Number:

 

Home Phone Number:

 

Age:

 

Date of Birth:

 

Notify in Emergency:

 

Address, City, State Zip:

 

Phone:

 

Business Address:

 

Phone:

 

Name of Personal Physician:

 

Phone:

PLEASE CHOOSE HOSPITAL PREFERENCE TO BE USED IN AN EMERGENCY:


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AUTHORIZATION FOR EMERGENCY TREATMENT

I authorize and direct the administration or medical representation to conduct whatever emergency medical action his/her judgment may deem advisable. In the event that

 

Applicant:

should suffer an accident or illness while a student, Mineral Area College is not responsible for my healthcare and will not purchase health insurance for me. I agree that health insurance and payment for healthcare services is my own personal responsibility (if student is 18 years of age or older):

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PERSONAL HEALTH HISTORY

History of Illness/Medical Problems:

List Injuries and/or Operations:

Any Permanent Disability?

List Physical Restrictions:

PLEASE LIST ALLERGIES, including latex allergies:

MEDICATIONS PRESENTLY TAKING (include name, dosage, frequency:

For a list of mandatory immunizations go to http://www.mineralarea.edu/faculty/academicDepartments/ems%20program/documents/EMSPogramsRequiredImmunications2016--2017.pdf

Note: these are NOT required upon acceptance. Immunization records and your completed physical exam is due during September per the course schedule.

*This information is provided to allow the college to access emergency care for you should it be required. These are questions that may be asked by EMS personnel.

MISSOURI REVISED STATUTES

A copy of the Missouri Revised Statutes regarding paramedic students can be accessed at the following website: http://s1.sos.mo.gov/cmsimages/adrules/csr/current/19c30-40a.pdf or a copy can be obtained from EMS Education.

Sections 19 CSR 30-40.340 on page 27 of the regulations should be read.

I know of no reason that I would be denied opportunity to sit for the National Registry Examination following my training.

I agree that I have read and understand the information listed above. I have also read and understand the regulations. I further agree that the information contained in this application is complete and accurate to the best of my knowledge.

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ESSENTIAL FUNCTIONS OF THE PARAMEDIC STUDENT 

Do you believe you would be able to perform the essential functions, listed below, necessary in the role of a paramedic student for which you are applying?

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If you answered NO to the above, are there any reasonable accommodations that you believe can be made that would permit you to perform the essential functions necessary in the role of a paramedic student?

Satisfactory completion of the Mineral Area College Paramedic Technology Program is contingent upon my being physically, mentally, and medically able, with or without reasonable accommodation, to successfully perform the essential functions necessary in the role of the paramedic student.

Following appropriate instructions and supervision, the paramedic student will: 

  1. Assess needs/conditions of patients utilizing the five senses. 
  1. Participate in planning the care of the patient. 
  1. Implement paramedic measures to give safe and effective care to patients, including:
    1. Administering physical care, which often requires moving/lifting clients and/or equipment.
    2. Performing paramedic procedures, which may require standing for extended periods and ability to stoop or bend. 
  1. Participate in the evaluation of patient care. 
  1. Communicate appropriately with patients, families, and other members of the health care team including:
    1. Verbal communication
    2. Written communication 
  1. Maintain a safe and appropriate environment for patients. 
  1. Attend class sessions, which may involve sitting for extended periods with short breaks periodically. 
  1. Take written scheduled examinations related to course/clinical curriculum.

I agree that I have read and have answered to the best of my knowledge the Essential Functions of the Paramedic Student:

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Date:

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PARAMEDIC PROGRAM APPLICATION QUESTIONNAIRE

Directions: Answer the following questions in complete sentences.

1) Why are you seeking education and training as a Paramedic?

2) What personal traits or characteristics do you have that will make you an effective paramedic student?

3) What are your personal or character strengths? What areas need improvement?

4) Explain why this is the right time in your life to pursue a career as a paramedic.

5) What are your expectations regarding the Paramedic Program?

6) Describe your current work experience. (You do not have to be working currently in EMS.)

7) Describe a past learning experience that you enjoyed.

Please contact Dean Meenach, Director of EMS Education, with any questions.  573-518-2113 or email: dmeenach@mineralarea.edu

Note: You may click the Save Application button to save your application and complete later.  You must enter an email address at the beginning of the application in order to receive the email with a link to access your saved application