Employer/CSN Communications
While enrolled in the paramedic program, do you plan on maintaining employment? ☐ Yes ☐ No
If you are accepted into the program and are employed with an EMS or fire agency - do you give the CSN EMS
faculty permission to discuss your progress with your agency’s Clinical Director/Manager or Chief of EMS as it
relates to your cognitive, psychomotor, or affective domain? ☐ Yes ☐ No
Criminal History
If you have been convicted of any type of felony crime, it is strongly advised you immediately contact the
Southern Nevada Health District Office of EMS Training and/or the National Registry of EMTs. Some felony
convictions will result in denial of licensure or certification as a paramedic or the ability to sit for these
examinations.
I have read the above statement and understand that both clinical placements and professional
certification/licensure is privilege not a right, which may be affected by my criminal background.
☐ Yes ☐ No
Program Expenses
I have reviewed the expected program expenses and understand that these are the responsibility of myself or
my sponsor. I realize that certain program activities, such as clinical rotations or internship placement, cannot
be started until all requirements have been met. It is my responsibility to ensure timely completion of all
program requirements and failure to do so may result in my removal from the paramedic medicine program.
☐ Yes ☐ No
Attestation
I attest that all the information on the application is accurate and complete to the best of my knowledge. I also
understand that falsification of any part of the paramedic medicine program application will result in
denial/removal from the paramedic medicine program and/or the College of Southern Nevada.
☐ Yes ☐ No
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