[City of Virginia Beach] Application for ALS Student Field Clinicals

Application for ALS Student Field Clinicals

Applications must be submitted 45 days prior to the official start date of the program in which they are pre-enrolled to apply for affiliation and/or scholarship.

Applicant Information

Phone Number

Enrolled Program Certification AEMT or PM

Released Certification with VBEMS EMT/AEMT/I

Officer Code:

Rescue Squad/VBFD Station

Supervisor Email:

Applying for

Affiliation Only - Applicant is taking classes towards higher level of EMS certification. Field clinical requirementswill be completed with Virginia Beach Department of EMS. The Virginia Beach Department of does not paytuition/fees.
Scholarship and Affiliation - Applicant is taking classes towards higher level of EMS certification. If awarded forscholarship, the Department of EMS pays a portion of tuition/fees for EMS related courses. Field clinicalrequirements will be completed with Virginia Beach Department of EMS.

Note: Funding is only available to active members released as an attendant in charge for a minimum of 1 year. Students completing clinical rotations MUST be enrolled in an EMS education course that has been announced to and APPROVED by the Virginia Office of EMS.

Applying for:

EMS Program Enrollment Information

Enrollment Information

AEC

Other (Program must have an approved MOU with the department)

TCC

Other (Program must have an approved MOU with the department)

Program Start Date

Program. End Date

Clinical/Field Start Date

Capstone Start Date

National Registry Testing Date

Certifications, Documents, and Identification – Submit current copies of all the following: Enter the date of expiration if no expiration date, or enter the date of initial certification.

Virginia EMT Date:

Virginia AEMT Date

Virginia Intermediate Date

Virginia Paramedic Date

NREMT - EMT Date

NREMT - AEMT Date

NREMT - Paramedic Date

TEMS Test Passed Date

TEMS Sanctioned Certificate Date

CPR Date

ACLS Date

PALS/PEPP Date

Student ID Date

Authorization for Release of Educational Information from an educational institution. Date

Upload File(s)

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Scholarship Applicants Only

For the Program for which I am enrolled in, I am requesting funding for:

Tuition/Fees

Books

National Registry Certification Exams

Other Information

1. Are you a Virginia resident for tax purposes?

State of Residence

2. Are you requesting financial aid or other financial assistance from another organization/agency?

Organization/Agency

Disclaimer and Signature

To the applicant’s immediate supervisor:

The applicant must have this application signed by their immediate supervisor who may include the following: VB Rescue Squad Commander, Assistant Squad Commander, VBEMS Captain, VBFD Captain, or VBFD EMS liaison.

By signing below verifies that the applicant is a member in good standing and approves the applicant for consideration for an ALS Field Clinicals with the City of Virginia Beach Department of EMS.

Date

Applicant Agreement

I have reviewed the ALS Class Notice and understand the requirements. With submission of this application, I understand that, at time of application and continuing until all contract obligations are met, I must:

 Adhere to Virginia Beach Department of EMS policies. Applicants have reviewed the ALS Training Policy, and the Certification and Credentialing Policy. Located on Lexipol or Vector Solutions.

 Virginia Beach Fire Department Employees

The maximum total hours consecutively on duty include field perception with the Department of EMS and working for VBFD is 36 hours.
The maximum total hours consecutively on duty include student field perception with the Department of EMS is 27 hours.
A minimum of 12 hours off-duty from all VBFD and Department of EMS is required if maximum eligible consecutive hours is reached.

 City of Virginia Beach Volunteers

ALS Student Classroom Only (Student in ALS course without clinical rotation requirements) – 36 hours released duty shifts per month.
ALS Student Classroom & Clinical (Student in ALS course with clinical rotation requirements) – 24 hours released duty shifts per month.
The maximum total hours consecutively on duty include student field perception with the Department of EMS and BLS duty is 27 hours.
A minimum of 12 hours off-duty from the Department of EMS is required between maximum eligible consecutive hours.

 Have/maintain CPR certification from a recognized program approved by Virginia Beach Department of EMS.

 Have/maintain current EMS certification recognized by the State of Virginia Office of EMS.

 Have no outstanding Vector assignments or expired Vector credentials.

 Have documented completion of required Virginia Beach Department of EMS training.

 Satisfy any contracts with Virginia Beach Department of EMS prior to start of the ALS field clinical and agree to sign a new training contract if requested (e.g. scholoarship)

 I understand I must complete an application for each semester that I am seeking scholarship/sponsorship. If I withdraw from a class, I must immediately notify the EMS ALS Coordinator with Virginia Beach Department of EMS

Applicant Signature

First Name

Last Name

Choose how to sign

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I understand I am applying for ALS affiliation to participate as an ALS student with Virginia Beach Department of EMS. Should I change course or level of certification for which I am approved, I may be required to submit a new application. I do hereby certify that the statements in this application are true and accurate to the best of my knowledge. I do hereby acknowledge my understanding of the requirements and obligations outlined in this application. I understand applying for ALS affiliation does not automatically mean approval. Eligibility, selection criteria, and scholarship awardee expectations are available on the department website, linked here.