SWORBHP Service Request for Training: Student Certification

THIS FORM IS TO BE COMPLETED BY A PARAMEDIC SERVICE.

If you are from a College and wish to request training, please complete the following form:

https://webforms.lhsc.on.ca/form/sworbhp-college-request-for-trai

Please note, the Student/College will be required to submit payment prior to training via cheque to LHSC as per the following:
PCP: $350
ACP: $500

SERVICE CONTACT INFORMATION

Please provide your contact information for follow-up.

Paramedic Service:

Name:

Work Email:

Phone #:

STUDENT PROFILE(S)

Student 1:

First Name:

Last Name:

Student #:

Student Identifier:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 2:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 3:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 4:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 5:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 6:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 7:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 8:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 9:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

Would you like to add another Paramedic?

Student 10:

First Name:

Last Name:

Student #:

Student Identifier:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

College:

Have you contacted someone at this college?

Contact Name:

Contact Email:

COMMENTS

Please feel free to provide additional comments/information: