Canadian Therapeutic College
Primary Care Paramedic Advance Standing & Preparatory Courses	Application Form

Date of Application:

Enrolment Date:

I. Personal Information

Name:
	SURNAME	FIRST NAME

Address:

City:

Postal Code:

Djjkjdkljsd

Telephone:

Date of Birth:

Gender:

M

F

E-mail address:

Languages:

Spoken:	English	French	Other:
Written:	English	French	Other:

                    II. Medical History

In order to be accepted by Canadian Therapeutic College, you must attach or have forwarded our entry

immunization form (provided by the College) indicating good health, freedom from all communicable

diseases and an up-to-date immunization and T.B test (if the T.B test is positive a yearly chest x-ray is

required as well as follow up treatment.)

III. Academic Education Training

Secondary School:

Completed Grade:

Or GED completed (  )

Post Secondary Institute:

(  ) Incomplete  (  ) Degree  (  ) Diploma

\

Post Secondary Institute:

(  ) Incomplete  (  ) Degree  (  ) Diploma

Attach copies of diplomas, degrees, certificates, and transcripts

I      V. Licensure (Advanced Standing)

License or Registration:

Date:

License College/Body:

Canadian Therapeutic College

Mail to: 760 Brant Street Burlington, ON. L7R 4B7 or Fax to: 905-632-2895

Telephone: 905-632-3200 or 1-877-278-8888

www.canadiantherapeuticcollege.com

	Canadian Therapeutic College
Primary Care Paramedic Advanced Standing & Preparatory Courses	Application Form

                     V. Character References

Please indicated two original reference letters of your good character from non-family members, who have

known you for more than two years. Letters must be signed, dated and include the individuals address and

phone number.

Name:

Address:

Occupation:

Telephone:

Years Known:

Name:

Address:

Occupation:

Telephone:

Years Known:

                      VI. Please check the following:

                     (  ) Current (written) criminal background check

\                    (  ) High School Diploma or GED

                     (  ) Other Diploma’s or Degree’s (Advanced Standing and Preparatory Course Credit Assessment)

                     (  ) Official Transcripts

                     (  ) Copy of course outlines for previously completed courses (Preparatory Course Credit Assessment)

                     (  ) Curriculum Vitae (detailed synopsis of academic and experiential background) (Advanced Standing)

                     (  ) Copy of Registration(s) and/or Licensure (Advanced Standing)

                     (  ) Copy of course outlines and/or curriculums from your training program (Advanced Standing)

                     (  ) Standard First Aid and Level C CPR

                     (  ) Appropriate application and testing fees

                    VII. Signatures

I agree to allow Canadian Therapeutic College collecting the personal information about me in this document in order to provide me with the services requested. I understand that the information is protected, treated confidentially and that I have the right to review that information.

Signature of applicant: ____________________________________ _Date: __________________________

I understand that there is a physical component to the Paramedic profession and each student must perform competently all two person lifts and transfers of patients weighing up to 90 kg (198lb.) and all of the necessary equipment for successful completion of from the program.

I understand that under the provisions of the Ambulance Act, a class “F” licence is required for employment as a paramedic and that employment is prohibited to (and therefore admission into the program will be denied to)** any individual who:

1) In the past year has received six (6) or more demerit points on his/her driving record.

2) Has had a driver’s license suspended in the previous two (2) years.

3) Has been prohibited from driving under the Criminal Code of Canada within the past three (3) years.

4) Has been convicted of any crime involving moral turpitude for which she/he has not been pardoned.

Signature of applicant: _____________________________________ Date: __________________________

_______________________________________________________________________________________

Canadian Therapeutic College

Mail to: 760 Brant Street Burlington, ON. L7R 4B7 or Fax to: 905-632-2895

Telephone: 905-632-3200 or 1-877-278-8888

www.canadiantherapeuticcollege.com