Canadian Therapeutic College
Primary Care Paramedic Preparatory Consecutive Course Declaration Form	Application Form

I. Personal Information

Name:			Student Number:
	SURNAME	LAST NAME

 (Change of Information Only)

 Address: ____________________________________ City: __________________ Postal Code: ______________

 Telephone: ____________________________________ Date of Birth: ___________________ Gender: M  F

 E-mail Address: _______________________________________________________________________________

II Course Information

Date of Application ______________________       Module # ________      Enrollment date: _______________________

                                                                                                                                                              Office Use (Prerequisite)

Course Name:__________________________ ______________________Course Code:____________                     

Course Name:________________________________________________ Course Code:____________                     

Course Name:________________________________________________ Course Code:____________                    

Course Name:________________________________________________ Course Code:____________                    

III. Signatures

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 Patient Care Lab classes.

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 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 driving 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.

I declare that:

1. none of the four points listed above apply to me.
2. since the last Criminal Record Background Check that I supplied to Canadian Therapeutic College or since the last Declaration given by me to Canadian Therapeutic College that I have no convictions under the Criminal Code of Canada up to and including the date of this Declaration for which a pardon has not been granted under the Criminal Records Act (Canada).
3. since the last Health / Immunization Form that I supplied to Canadian Therapeutic College or since the last Declaration given by me to Canadian Therapeutic College that my physical or mental health has not deteriorated so as that I am not capable to participate in any course or clinical placement by reason of injury or illness.
4. My CPR and First Aid Certificates are current and will remain current during my course
5. My immunizations as indicated on my Health Form have been maintained

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