{"id":388,"date":"2015-03-05T19:41:35","date_gmt":"2015-03-05T19:41:35","guid":{"rendered":"https:\/\/www.palomar.edu\/eme\/?page_id=388"},"modified":"2026-01-21T09:14:08","modified_gmt":"2026-01-21T17:14:08","slug":"paramedic-accreditation-application","status":"publish","type":"page","link":"https:\/\/www.palomar.edu\/eme\/paramedicacademy\/san-diego-county-paramedic-accreditation\/paramedic-accreditation-application\/","title":{"rendered":"SD County Paramedic Accreditation Application"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">San Diego County Paramedic Accreditation Application<\/h3>\n                            <p class='gform_description'>Application to attend Paramedic Accreditation workshop<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/eme\/wp-json\/wp\/v2\/pages\/388' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_2'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Middle Initial<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_6' id='input_1_6' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>E-mail address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Workshop date preferred<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Name and location of original training agency where you received your paramedic training<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Date of original accreditation (when you completed your paramedic training)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>County\/State of current accreditation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>CA State Paramedic License Number (If applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are you attending this workshop for a Field Internship in San Diego County?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_13'><li class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Yes'  id='choice_1_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='No'  id='choice_1_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please Indicate which of the following that you have NOT been tested on<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_14'><li class='gchoice gchoice_1_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Interosseous Infusion'  id='choice_1_14_1'   aria-describedby=\"gfield_description_1_14\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_1' id='label_1_14_1' class='gform-field-label gform-field-label--type-inline'>Interosseous Infusion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='External Jugular IV Access'  id='choice_1_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_2' id='label_1_14_2' class='gform-field-label gform-field-label--type-inline'>External Jugular IV Access<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='AV Fistula\/Shunt, Indwelling IV Catheter Access'  id='choice_1_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_3' id='label_1_14_3' class='gform-field-label gform-field-label--type-inline'>AV Fistula\/Shunt, Indwelling IV Catheter Access<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='ET intubation, Bougie and King Airway Insertion with LEADSD'  id='choice_1_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_4' id='label_1_14_4' class='gform-field-label gform-field-label--type-inline'>ET intubation, Bougie and King Airway Insertion with LEADSD<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='NG Tube and Gastric Suction'  id='choice_1_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_5' id='label_1_14_5' class='gform-field-label gform-field-label--type-inline'>NG Tube and Gastric Suction<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='Length Based Resuscitation Tape and Pediatric Drug Sheets'  id='choice_1_14_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_6' id='label_1_14_6' class='gform-field-label gform-field-label--type-inline'>Length Based Resuscitation Tape and Pediatric Drug Sheets<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='CPAP'  id='choice_1_14_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_7' id='label_1_14_7' class='gform-field-label gform-field-label--type-inline'>CPAP<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.8' type='checkbox'  value='Hemostatic Gauze and Tourniquet application'  id='choice_1_14_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_8' id='label_1_14_8' class='gform-field-label gform-field-label--type-inline'>Hemostatic Gauze and Tourniquet application<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.9' type='checkbox'  value='Push-dose Epinephrine prep and administration'  id='choice_1_14_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_9' id='label_1_14_9' class='gform-field-label gform-field-label--type-inline'>Push-dose Epinephrine prep and administration<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_14_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.11' type='checkbox'  value='SD County Standard Radio Report practice'  id='choice_1_14_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_11' id='label_1_14_11' class='gform-field-label gform-field-label--type-inline'>SD County Standard Radio Report practice<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_14'>At least one box must be checked.<\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you hereby affirm that the information submitted on above form is true and correct? (Signature will be requested at time of course to affirm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_15'><li class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Yes'  id='choice_1_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='No'  id='choice_1_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-multiselect gfield--input-type-multiselect field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Submit copies of the front and back sides the following to ado@palomar.edu :<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_16[]' id='input_1_16' class='medium gfield_select'   aria-invalid=\"false\"  aria-describedby=\"gfield_description_1_16\"><option value='State Medic License' >State Medic License<\/option><option value='ACLS Card' >ACLS Card<\/option><option value='Picture ID' >Picture ID<\/option><option value='Course Completion Record' >Course Completion Record<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_16'>*This course includes all San Diego County protocol updates.\n\n** You will be required to provide your Social Security Number at the time of the course.<\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n        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