Instructions: Print and use this form as a coversheet to your packet of materials to document

compliance with the following prerequisite, co-requisite, and medical/physical requirements.

For proof of medical/physical requirements, students may use their own physician or they may use
the services of the University Student Health Services (SHS). As of fall 2012, non-credit students
pay $15 per visit plus the cost of services, such as immunization shots. If using Student Health
Services, you must bring a government issued photo ID or College ID to all appointments. More
information is available on the SHS website.
CSULBs Associated Student, Inc. (ASI) manages a health insurance plan for students through
United Health Care. You can call ASI at (562) 985-4994 for more information or visit the United
Health Care website for the campus. Spring/summer 2012 plans ranged in price from $529 to
$1,154 for a 20-year old student living in Long Beach. Or, students may provide evidence that they
are using their own individual or family policy.
EMT students can receive discounted rates for professional liability insurance. You can search for
providers on your own. However, the National Association of Emergency Medical Technicians
(NAEMT) has endorsed the Healthcare Providers Service Organization (HPSO) for liability
insurance (about $20) per year for EMS Basic students. More information can be found on the
HPSO website.
The University Police Department can assist you in meeting your Live Scan Fingerprinting
requirement. The Live Scan hours are 1 to 4 pm, Monday though Thursday, at the main station
located at the south end of lot 11C. The cost is $20 plus DOJ fees. Cash, check or money order
accepted. Reservations cannot be made. More information is available on the University website.
IMPORTANT: Staple this form as a cover page to all materials indicating compliances.

Student Name (print): ______________________________________

EMT Student Requirement
Program Office
Approvals
1. Current American Heart Association (AHA) BLS Healthcare Provider Card or
Current American Red Cross (ARC) Professional Rescuer Car. Include a copy
of both the front and back of the card.

2. Background Check Live Scan fingerprinting (Info)
3. Physical Health Clearance An original signed and dated form from a
physician within six months before the start of class specifying that you can
participate in the clinical portion of the EMT program without physical limitation.
Use the form called Physical Clearance Form provided on the next page in this
booklet.

4. Hepatitis B Vaccine, titer or declination (Info)
5. Influenza vaccine or declination (Info)
6. Current measles/mumps/rubella (MMR) immunization or titer (Info)
7. Tuberculosis (TB) screening annual (Info)
8. Current combined Tetanus, Diphteria, and Pertussis vaccine Td/Tdap (Info)
9. Current varicella (chicken pox or VZV) immunization or titer (Info)
10. Proof of health insurance (copy of both front and back of card)
11. Proof of liability insurance If submitting a card, include a copy of both front
and back of card.

12. Completion of HIPAA Training This is a homework assignment you must
complete and available on BeachBoard.

13. Signed Student Policy Certification See form later in this section.
14. Signed CSULB General Release of All Claims See form later in this section.

CSULB Hospital Clinical Experience and Ambulance
Ride-Along Prerequisites and Co-Requisites
COVERSHEET

CALIFORNIA STATE UNIVERSITY, LONG BEACH
GENERAL RELEASE OF ALL CLAIMS


In consideration of my participation in the voluntary, extracurricular activity
described below, I hereby agree to assume all risk of any kind of injury or damage I may receive
or sustain as a result of my participation, including property damage, bodily injury, personal
injury or death. Accordingly, by signing below, I hereby completely release and hold harmless
and forever discharge the State of California; the Trustees of the California State University;
California State University, Long Beach; and each and every representative, employee, officer,
volunteer, and agent of each of them, from liability or responsibility for any and all claims,
damages, injuries, losses or causes of action that may result from or arise out of my
participation in the described activities. I also understand and agree that this release shall be
binding as against my heirs and assigns.

Activity: Hospital Emergency Room Clinical Experience and/or Ambulance Ride-Along

Dates: ___________________________________

Location: ___________________________________________________________________

Description of Event Activities: To successfully complete the CSULB EMT training and be
eligible for certification, students must complete a minimum of 12 hours of hospital clinical and
12 hours of ambulance ride-along experience. The purpose of these requirements is to give
students the opportunity to observe emergency department and ambulance operations for a
period of time sufficient to gain an appreciation for the continuum of care that students must
perform. During these activities, students must be under the supervision and control of a charge
nurse (hospital) and at least two certified EMTs and/or paramedics (ambulance ride-along) or
combination thereof.

Types of Risks Involved with the Activity: Bodily injury, personal injury or death. Personal
property damage. Personal property loss.

Participant Name (Print) ____________________________________________________

_______________________________________________ ___________________
Participant Signature Date

_____________________________________________________
Print Name of Parent or Legal Guardian (if under 18 years of age)

___________________________________________ __________________
Signature of Parent or Legal Guardian Date

CSULB EMT Program
Student Declination Form

I decline to obtain a hepatitis B vaccine.
I decline to obtain a influenza vaccine.

Student Name (print): ____________________________________


Student Signature: _________________________________ Date: ______________________



CSULB EMT Program
Student Policy Certification

I have read and understand the expectations and requirements to participate in the CSULB
EMT Education Program and agree to meet policy expectations for the Program. I understand
that failure to meet the requirements may result in my termination from the CSULB EMT
Program. I also agree to conduct myself as a professional and in a manner consistent with
University policy and EMT Program expectations.

Student Name (print): ____________________________________


Student Signature: _________________________________ Date: ______________________