Applications were due by September 30, 2013

FIRST RESPONDER/EMT TRAINING SUBSIDY APPLICATION FOR TRAINING FUNDS
July 1, 2013 - June 20, 2014

Regional EMS funds are again available to official First Responder Squads in Southeastern Minnesota for the following courses: First Responder Certification, First Responder Recertification, Emergency Medical Technician Certification, and Emergency Medical Technician Recertification.  A squad can apply for EMS funds to meet the training needs of both new and current members.  Following is the allocation per person for each program:

First Responder Certification ($175)

First Responder Recertification ($100)

EMT Certification ($300)

EMT Recertification ($125)

BLS ambulance services who have a hardship variance and are using First Responders on their service CAN apply for the FR training funds! They are not, however, eligible for the EMT training funds because that is available through the EMSRB. Ambulance services only need to complete contact info and # to be trained.

NOTE:  Acceptance of application does not guarantee payment for all requests for reimbursement.  Eligible reimbursements are paid on a first come, first served basis until the funds allocated for the fiscal year have been depleted.

PLEASE PRINT

 

                                                                                              _____________________________

 _____________________________________________________________________________

Organization                                                                                                   Contact

                                                                      ___________________________________________

Address                                       City                        State                Zip Code                    County

                                   ______________                                                                                   _____

Daytime Telephone Number                                         Email                                                 

Estimated number of individuals to be trained for following classes:

 

First Responder Certification                       First Responder Recertification          _

 

EMT Certification                                        EMT Recertification ________              

 

 

GENERAL INFORMATION

 

If application is for an existing Squad, complete Section A. If you are seeking funds to offset EMT training, complete Section B.

SECTION A

1.         Last First Responder Course offered                                                 __________________

2.         Training institution                                                                             __________________

3.       Number certified                    ____________   Current number of members                __

4.       Approximate number of runs per year                                                _________________

5.       Does Squad use run report forms:    YES    NO  Source              ____________________

6.       Does squad have direct radio communications with ambulance service:    YES     NO

7.       Does Squad have regular meetings/training sessions:    YES     NO

SECTION B

NOTE:  Subsidy is limited to FOUR members per year for EMT Certification OR Recertification.  Individuals must have a minimum of TWO YEARS on an official First Responder Squad to be eligible.

8.                                     _________ Circle:  EMT or EMT Recert  # Years on Squad:_______

                  First Individual’s Name

9.                                     __________Circle:  EMT or EMT Recert  # Years on Squad:______

              Second Individual’s Name

10.                                     __________Circle:  EMT or EMT Recert  # Years on Squad:______

                 Third Individual’s Name

11.                                     __________Circle:  EMT or EMT Recert  # Years on Squad:______

                 Fourth Individual’s Name

Application can be returned via email, fax, or mail BEFORE SEPTEMBER 30, 2013.

 

                                                                     ____                                                                 _______

                          Signature                                                                             Date   

 

Revised: June 2013