EMS Academy Course Request Form

Please fill out the following form to request a course affiliated with the EMS Academy. Please submit your course request 60 days in advance of course start date. Beginning March 1, 2017 course requests received less than 45 days in advance of start-date are subject to a $500.00 expediting fee along with the regular approval process. A course request is considered submitted on the day that the EMS Academy receives it with no missing components.

Phone
Is this a credit class being offered through a branch or partner campus?*
Course Type*
Initial Licensure Level to be Taught*
Requesting that EMS Academy secure an Instructor*
Instructor same as Submitter

Enter Gmail address for the lead instructor. If the Lead Instructor does not have a Gmail address, enter here an email address that can access GoogleDocs.

Phone
Who is providing/paying the lead instructor?*
Assistant Instructor Planned?*

Minimum hours

  • First Responder: 80
  • EMT-Basic: 192
  • EMT-Intermediate: 192
Sufficient Hours?

Minimum hours

  • First Responder: 80
  • EMT-Basic: 192
  • EMT-Intermediate: 192

Lead must teach 80% or more of total course hours if Assistant is not a UNM Affiliated Instructor Coordinator.

Assistant can teach up to 20% of total course hours if they are not a UNM Affiliated Instructor Coordinator.

Phone
Who is providing/paying the assistant instructor?*
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Hybrid Component Requested
Moodle Requested

If you’re interested in using Moodle for your course check here. It is a completely instructor-managed process once we set up the course for you.

Name of facility where the class will be held, if known. Leave blank if unknown/undecided.

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Street address of the facility above.

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Does this location have a projector to hook up to a laptop?*
Does this location have a screen or white wall to project upon?*
Does this location have the ability to make copies?*
Registration Closed or Open*

This course is intended only for:

I understand this is an unrestricted course. I will promote this course to the surrounding area.

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The service or agency issuing the PO that will cover the full course cost.

Course Fee Disclaimer: The EMS Academy strives to offer quality EMS licensure classes throughout New Mexico. In order to keep the cost as reasonable as possible for all participants, the total cost of the course is split amongst those registered.*

The course minimum will be set at 6 so the course price begins at the total cost divided by 6.


Should enrollment exceed the minimum set, all those enrolled will receive a partial refund or, in the case of POs, a revised quote/invoice after the first day of class so that the course cost is split evenly among all participants.


Please check here to acknowledge you understand the above. Call 505-272-2743 for any questions.

Considering the space and needs of the requesting party.

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Course Supplies*

Are course supplies being requested? (Books are automatically included for certificate-only classes)

Name of the person we'll work with for the trailer delivery. If it's not the requestor or instructor, include contact information.

By selecting "No" I have verified that the sponsor providing supplies for this course is aware of, and will provide, all the supplies required to successfully train the students competently to the level being taught. I attest that the supplies provided, in type and quantity, will either match or exceed the supplies that would be provided by the EMS Academy for this same course.

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Indicate the reason for requesting Standardized Assessments in lieu of, or in conjunction with, Clinicals.

Courses requesting all SAs, if approved, will have all SAs complete by the last day of the course.

Clinical shifts for students taking classes held within the greater Albuquerque area are coordinated by the EMSA Director of Clinical Education.

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I attest that there are sufficient clinical resources available for the maximum requested number of students, with regard to the clinical sites noted here. I understand I am responsible for arranging clinical shifts for the students of this course.

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The date selected falls outside the possible range for a proposed course. Select another date.

Completed if there is not a firm start date planned or if start date is left blank.

This start date is less than 45 days out. Check here to acknowledge understanding that, if this class is an initial licensure class, a $500 expediting fee will be assessed to the total cost of the course.

This start date is less than 60 days out. Check here to acknowledge understanding that there might not be enough time to secure enough participants for the course.

8 hour classes need an hour break in middle.

Enter in 4 or 8 hour time blocks (unless you are a branch or college partner campus). Classes longer than 4 hours need a minimum 1/2 hour break in middle. 8 hour classes need an hour break in middle.

Meeting on Monday every single week?*

List here the Mondays that you will be missing due to a holiday, etc.

8 hour classes need an hour break in middle.

Enter in 4 or 8 hour time blocks (unless you are a branch or college partner campus). Classes longer than 4 hours need a minimum 1/2 hour break in middle. 8 hour classes need an hour break in middle.

Meeting on Tuesday every single week?*

List here the Tuesdays that you will be missing due to a holiday, etc.

8 hour classes need an hour break in middle.

Enter in 4 or 8 hour time blocks (unless you are a branch or college partner campus). Classes longer than 4 hours need a minimum 1/2 hour break in middle. 8 hour classes need an hour break in middle.

Meeting on Wednesday every single week?*

List here the Wednesdays that you will be missing due to a holiday, etc.

8 hour classes need an hour break in middle.

Enter in 4 or 8 hour time blocks (unless you are a branch or college partner campus). Classes longer than 4 hours need a minimum 1/2 hour break in middle. 8 hour classes need an hour break in middle.

Meeting on Thursday every single week?*

List here the Thursdays that you will be missing due to a holiday, etc.

8 hour classes need an hour break in middle.

Enter in 4 or 8 hour time blocks (unless you are a branch or college partner campus). Classes longer than 4 hours need a minimum 1/2 hour break in middle. 8 hour classes need an hour break in middle.

Meeting on Friday every single week?*

List here the Fridays that you will be missing due to a holiday, etc.

8 hour classes need an hour break in the middle.

Enter in 4 or 8 hour time blocks (unless you are a branch or college partner campus). Classes longer than 4 hours need a minimum 1/2 hour break in middle. 8 hour classes need an hour break in middle.

Meeting on Saturday every single week?*

Indicate here if you are only meeting on select Saturdays and list the dates or, if you are meeting every Saturday, list the days that you will be missing due to a holiday, etc.

8 hour classes need an hour break in the middle.

Enter in 4 or 8 hour time blocks (unless you are a branch or college partner campus). Classes longer than 4 hours need a minimum 1/2 hour break in middle. 8 hour classes need an hour break in middle.

Meeting on Sunday every single week?*

Indicate here if you are only meeting on select Sundays and list the dates or, if you are meeting every Sunday, list here the days that you will be missing due to a holiday, etc.

Will this schedule match exactly what will be posted in your school's schedule of classes?*

If this schedule will not match your institution's schedule of classes explain how this difference in course operation/attendance expectation (course days, dates, times, instructor, delivery method, etc.) will be communicated to the students prior to their registration.

For First Responder/EMR, or EMT-Basic/EMT classes completing all SAs, this is the last day of class.

Can upload planned class schedule, hous calculation, or anything else that has been prepared for this request.

Drag and drop files here or

Explain anything here not noted in the questions answered above that needs to be considered for this class (virtual component requested, etc.).