Fillable Printable Student Permission Form - Virginia
Fillable Printable Student Permission Form - Virginia
Student Permission Form - Virginia
Page 1
Virginia Office of Emergency Medical Services
www.vdh.virginia.gov/oems
EMS.TR.07
Revised: July 2011
Student Permission Form for BLS Students
Less than 18 Years Old
Virginia Office of EMS
Division of Educational Development
1041 Technology Park Drive
Glen Allen, VA 23059
804-888-9120
Dear Parent/Legal Guardian:
Your daughter/son has expressed an interest in being certified as an Emergency Medical Services Provider. The Office of
Emergency Medical Services, Virginia Department of Health requests that you take a moment to review this letter. If you have
any concerns, please discuss them with your daughter/son, the EMT instructor, or someone at the Office of Emergency
Medical Services. (1-800-523-6019)
The Emergency Medical Services (EMS) Basic Life Support (BLS) Course is a program which trains people to assist injured or ill
individuals outside the confines of a hospital. The curriculum used in Virginia is a nationally recognized program developed by
the U.S. Department of Transportation.
The curriculum requires a minimum of number of hours of classroom instruction and for Emergency Medical Technician
programs an additional 10 hours of clinical experience either by hospital emergency department observation, or a ride-a-long
on an ambulance. Following successful completion of a State approved course, the student is allowed to take the State
Certification Examination. Passing both the written and practical aspects of the State examination certifies the student to
perform the duties of an EMS provider.
Because of the responsibilities placed on an EMS provider, the State of Virginia requires that anyone less than eighteen (18)
years of age must have permission from their parent or legal guardian to become certified as an EMS provider in Virginia. The
individual must be at least sixteen (16) years of age before the course starts to enroll in an EMS program.
To participate in the delivery of health care can be a very rewarding experience. However, the responsibilities of an EMS
provider are great and at times extremely stressful. The balance of a patient's life may rest with the actions taken by the
provider. The consequences of such situations can be positive; but can also be a source of frustration, guilt, and emotional
distress. Physical injury is also a very real possibility.
EMS providers are at a greater risk of exposure to infectious diseases, hazardous environments, and violent behaviors.
Emergency Medical Services' training programs provide information on how to protect oneself when dealing with these
hazards. However, the nature of EMS activities tends to place EMS providers in dangerous situations where the maturity and
experience to deal with critical decisions is of the most importance.
APPLICANT/STUDENT INFORMATION:
Name
Last Name First Name MI
Mailing Address
+
Number, Street, Apt. City State Zip +4
E-mail Address
(over)
Page 2
Virginia Office of Emergency Medical Services
www.vdh.virginia.gov/oems
EMS.TR.07
Revised: July 2011
Student Permission Form for BLS Students
Less than 18 Years Old
Virginia Office of EMS
Division of Educational Development
1041 Technology Park Drive
Glen Allen, VA 23059
804-888-9120
PARENTAL ACKNOWLEDGMENT:
By signing this document, you agree that your daughter/son has the capabilities of managing these mature matters. The Office
of Emergency Medical Services welcomes all interested individuals to participate as an informed member in this very
rewarding activity.
I have reviewed this letter and discussed with my daughter/son the activities associated with being an EMS provider. Having
no further questions, I consider to possess the necessary maturity to perform the duties of an Emergency Medical Services
Provider and authorize their enrollment in this EMERGENCY MEDICAL RESPONDER or EMERGENCY MEDICAL TECHNICIAN
course.
Signature Date
Relationship to Applicant:
AGENCY ACKNOWLEDGMENT:
If the applicant is a member of an agency providing prehospital medical care, the endorsement of the applicant by an officer
in the agency is required to insure agency insurance coverage, etc. in the event of student’s course related injury or liability.
I, the undersigned individual have spoken to the applicant’s parent or guardian and I recommend that the applicant, a
member in good standing with the agency specified below, be allowed to take the Emergency Medical Responder or
Emergency Medical Technician program for certification.
Agency Name
Agency Official Name
Last Name First Name MI
Official Title
Mailing Address
+
Number, Street, Apt. City State Zip +4
E-mail Address
Signature Date
This letter must be presented to the EMT Instructor who will keep it on file with the records for the Emergency Medical
Services program the above applicant has enrolled. This letter must be returned to the EMT instructor
within one week after receipt by the student in order to remain in the course.
