BREMSS EMS Training

Today's Date *

EMS Region *

Course Type *

Course Approval Number *

This number should be acquired from the course coordinator or instructor. The correct number will have the format "23-EMT-R3-.xxxx".

Group *

County *

Course Start Date *

Course End Date *

Course Coordinator Information *

Check the box to verify the Course Coordinator information.

First name *

Last name *

Email *

Primary Instructor Same as Course Coordinator

Check box if the Primary Instructor information is the same as the course coordinator.

Instructor First Name *

Instructor Last Name *

Instructor Email Address *

Last 4 of S S N (XXX-XX-XXXX format) *

This is needed for NREMT testing authorization upon successful completion. Do not enter your full number.

First name *

Middle Name

Last name *

Email *

Confirm the previous field *

Home Phone

Mobile Phone *

Student Street Address *

Student City *

Student County *

Student State *

Student Zip Code *

Is your employer sponsoring your course? *

EMS Region *

County *

Agency / Sponsor name *

Type of Agency *

Other *

Job title *

Street

City

State

Zip code

Phone

Level of Education *

Other *

Grade Level *

Have you ever been convicted of a felony? *

Have you ever been convicted of a DUI? *

Are you now or have you ever been addicted to controlled substance or intoxicating liquors? *

Have you ever been treated for mental illness? *

Is your eyesight impaired in any manner? *

If yes, is it corrected? *

Have you ever had any type of professional license revoked, suspended or surrendered? *

If yes, provide a written explanation. *

I have received an explanation of the total cost for my EMS course. *

Total cost of course *

If this is a free course enter 0.

I have received a written explanation of the training program’s accreditation and college credit information prior to the beginning of the course. Information included explanation of my current training program accreditation status, eligibility of college credit, eligibility to attend more advanced EMS courses, and contact information for two (2) nearby accredited college EMS programs. *

I understand I must receive HIPPA education from my EMS course and sign a confidentiality statement. *

I understand that as a participant EMS student I may have access to, or witness first hand, patient care information that is confidential. This information may include a patient’s identity, current injury or illness, and past medical history. Understanding that the confidentiality of this information is protected by law, I shall: *

1. Respect and maintain the confidentiality of all patient care information, discussions, deliberations, records, or other information connected with my participation in the EMT education Program. 2. Make no voluntary disclosures regarding any patient care information, discussions, deliberations, records, or other information generated in connection with my participation in the EMT education program, except to those individuals who are authorized to receive it.

I understand that any breach of confidentiality is detrimental to the EMT program and to its mission of EMT education, including the field training hours at hospitals and EMS providers, and further acknowledge that any breach of confidentiality may result legal proceedings for the individuals involved. *

I understand that any breach of confidentiality may also be detrimental to the patient and the patient’s family. *

Examples of unacceptable disclosures include, but are not limited to: × Discussion of any patient information with anyone not directly involved with that patient and patient care. × Discussion of an event which might identify a patient, even though the patient’s name is not disclosed. × Discussion of injuries or medical history in such a manner that the information could be associated with the patient. × Discussion, outside of EMT rotations, of any event or occurrences dealing with patient information, including injuries or medical history.

Having read the above statement, I hereby certify that I have received a confidentiality briefing (HIPPA) by the instructor teaching my EMS class. *

Enter your legal name

I fully understand the sensitive and confidential nature of the data and information received by myself from patients, practitioners and providers of health care, as a result of patient care functions. I shall not knowingly or willingly communicate, deliver, or transmit in any manner, patient information to any unauthorized person or agency. *

I understand that due to my educational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I, the undersigned, hereby knowingly and voluntarily waive, release and discharge the EMS Program and its officers, employees, and agents (hereafter collectively called the School) from any and all claims for damages for personal injury, including death, and damages to property. This release is intended by me to discharge in advance the School from and against any and all liability arising out of or connected in any way with my enrollment in the EMS Field Course through the School even though that liability may arise out of negligence or carelessness on the part of the School. *

I understand that as part of my participation in the EMS field classes I may perform, participate in, or observe a variety of activities which can be dangerous. I further understand that in response to emergencies and rendering emergency life saving measures serious accidents can occasionally occur. I acknowledge that individuals engaged in or performing lifesaving activities and functions occasionally sustain personal injuries, such as, but not limited to lacerations, sprains, and possible exposure to and contraction of the HIV virus. Knowing and understanding the risks involved in the EMS Field classes, nevertheless, I hereby agree to assume any and all risk of injury and further judgments, claims, damages of, connected with, or resulting from my enrollment in and participation in the EMS Field class of the School. *

I acknowledge that I have read this document and that I am relying wholly upon my own judgment, belief and knowledge of the risks of injury to myself by enrollment in and participation in the EMS Field classes through the school. As of the date of this agreement, I am 18 years of age or older. *

Students under 18 must have a signature from a parent or legal guardian.

I have completed the Hepatitis B Series *

I acknowledge and have read and understand the policies and procedures set forth in the background screening policy located at https://online.bremss.org/emr-student-registration/pages/background-screening-policy. *

By signing this document, I am indicating that I have read, understand, and voluntarily agree to the required background agents if deemed necessary. I understand that these results are confidential and will not be otherwise released without my authorization. I hereby release the EMT Program, ADPH OEMS&T, EMS Regional Office, and its affiliates from any and all liability, claims, and/or demands of whatever kind related to my completed background screen. *

Enter digital signature in the form field

I have read, understand, and agree to the drug scree guidelines (located at https://online.bremss.org/emr-student-registration/pages/student-drug-screen-policy). I hereby release DRUG TEST COMPANY the Medical Review Officer, the Conducting School, the program facility, and the Alabama Department of Public Health and its Designees from any claim in connection with the Drug Screen Policy. I understand that should any legal action be taken as a result of the Drug Screen Policy, that confidentiality can no longer be maintained. *

https://online.bremss.org/emr-student-registration/pages/student-drug-screen-policy

By signing this document, I am indicating that I have read, understand, and voluntarily agree to the required drug screen. I understand that these results are confidential and will not be otherwise released without my authorization. I hereby release the EMT Program, ADPH OEMS, EMS Regional Office, and its affiliates from any and all liability, claims, and/or demands of whatever kind related to my completed background screen. *

Enter digital signature into the form field.

NREMT Certification Number *

EMT License Number *

Upload a copy of your Alabama State EMS License

Allowed file formats: .jpg, .jpeg, .zip, .rar, .png, .bmp, .pdf, .docx, .doc, .pptx, .ppt, .mp4, mp3, m4a, wav, .ics, .webp, .gif, .xlsx, .xls, .csv Maximum file size: 20Mb

NREMT Expiration Date *

State EMS License Expiration Date *

I affirm that I have read and understand the EMS student requirements and standards set by the ADPH Office of EMS. *

To the best of my ability and knowledge, all the statements contained in this student registration form are true and accurate. *

I further understand that a breach of this policy can result in my immediate dismissal from the EMS Course and that I could also face legal consequences. *

Student Electronic Signature *

Approved EMR Courses

Approved EMT Courses

Approved Advanced EMT Courses

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