Community Paramedic (EMS) Pre-Registration Screening Form

This form serves as a Pre-Registration Screening for the CNM Community Paramedic Program (EMS).

Need Help?

If you have any questions about this form, please call (505) 224-4111 or email cpe@cnm.edu before submitting.

Before Submitting This Form

Please read the screening criteria and guidelines for the Coordinated Entry Programs.
Please read the instructions for the Community Paramedic (EMS) Pre-Registration Screening Form.

You cannot "save" your work and return to it later.

Submission of your form does not guarantee you a seat in the program. Screening forms will not be considered for students who have not been admitted to CNM.

Last Name

First Name

CNM ID Number Nine-digit number only, no hyphens or spaces.

Primary Phone Please include area code when entering phone number (XXX-XXX-XXXX)

CNM E-Mail Address NOTE: This is the ONLY way we will contact you regarding your screening form. Make sure the address is working properly and check your account frequently. If you are experiencing any difficulties, contact Information Technology Services (ITS) at (505) 224-4357.

License Number Please enter your current EMT-P New Mexico License number.

Employer/Organization Submitting Documentation of Experience Form Write the name of the company/organization(s) that will be submitting a form on your behalf. Form must be received by the deadline in order to be considered.

Screening Term of Entry Which term are screening for entry to begin the Community Paramedic program?

Fall 2018
Spring 2019

Information and Acknowledgements

For each of the following statements click the box to acknowledge you understand that you have met/will meet the following requirements. If you have any questions on any of these statements, please contact (505) 224-4111 or email cpe@cnm.edu before submitting this form.

I understand that I must meet the minimum requirements for this program which include: 3-5 years of EMS experience, a current New Mexico EMT-P license or current National Registry Paramedic License.

I understand that there are limited seats for this program. I will be responsible for registering for courses at the assigned date and time.

I understand that failure to submit transcripts or meet program requirements will delay my ability to register for this program. I also understand that my academic or financial aid status may effect my ability to to successfully register for this program.

I understand that if I am able to register for this program, I must complete pre-entry requirements by a deadline, including attending a program orientation, and completing a background check, drug screen, and immunizations. More information on compliance for this program can be found at the Office of Verification and Compliance.

I understand that I must become familiar with the School of Health, Wellness, and Public Safety Handbook. The School of Health, Wellness, and Public Safety Handbook.

Signature My signature confirms that I have read and agreed to all of the terms and conditions required to qualify to register for this program.

Type the words shown below.

When you click "submit" a screen will appear that will notify you that your form was submitted successfully. You will also receive an email confirmation to your CNM email account.

Community Paramedic (EMS) Pre-Registration Screening Form

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Before Submitting This Form

Information and Acknowledgements

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