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Yolo County Emergency Medical Services Agency (YEMSA)

yemsa@yolocounty.org

137 N Cottonwood St Woodland, CA 95695

530-666-8615

EMERGENCY MEDICAL RESPONDER (EMR) RENEWAL APPLICATION

For RENEWAL Certification Only

You must have documents electronically copied (cards & forms)
PRIOR to starting the online application process.

Be sure to read carefully and answer all questions.


Date of Birth:

Enter your Personal Mailing Address:


I understand that I am solely responsible for notifying YEMSA in writing, within thirty (30) calendar days, of any changes to my mailing address or contact information? (A change of address form can be found on the YEMSA's website.)



Background Disclosure:

If you answer YES to any of the NEXT three (3) questions, then you MUST add/attach a detailed statement.

*Note: A box will open once you click YES to add/attach statement.


1. Have you ever had a certification, accreditation, or professional healing arts license denied, suspended, revoked or placed on probation, or are you under investigation at this time? If yes, you must add/attach a detailed statement with this application that describes the action, any corrective action, and/or remediation as a result of the action.

YES, to question #1 - ATTACH a detailed Statement HERE or write it above that describes the action, any corrective action, and/or remediation as a result of the action.

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2. Have you ever been convicted of any felony or misdemeanor offense in California or in any other state or place, including entering a plea of nolo contendere or no contest, and including any conviction which has been expunged (set aside) or records sealed under Penal Code § 1203.4? If yes, you must add/attach a detailed statement describing the crime(s), date, location, court, sentence served, and parole if any. You must also attach any applicable court documents and police reports.

YES, to question #2 - ATTACH a detailed Statement HERE or write it above describing the crime(s), date, location, court, sentence served, and parole if any. You must also attach any applicable court documents and police reports.

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3. Are there any criminal charge(s) currently pending against you? If yes, you must add/attach a detailed statement describing the charge(s), date, location, and court, if any. You must also attach any applicable court documents and police reports.

YES, to question #3 - ATTACH a detailed Statement HERE or write it above describing the charge(s), date, location, and court, if any. You must also attach any applicable court documents and police reports.

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RENEWING CERTIFICATION
REQUIRED DOCUMENTATION

  • The below requested documentation copies must be uploaded/attached for online application submission.
  • All documentation must be current, legible, and is subject to verification.
  • If all card copies are printed on one (1) page, you may upload the same page multiple times.

Maintaining Certifications:

I understand it is my responsibility to have current/valid certifications on file at all times with YEMSA. This means if a certification expires during my EMR certification period it is my responsibility to submit a current copy to YEMSA. (Emailing a copy is the preferred method of submission)


YEMSA EMR Certification Card:

When does your current expiring YEMSA EMR Certification expire?

ATTACH HERE a copy of your current expiring YEMSA EMR Certification Card showing expiration date.

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Photo ID:

Examples: State Driver’s License, State ID card, Military ID card, Passport.

When does your Government Issued Photo ID expire?

ATTACH HERE a copy of your Government Issued Photo ID Card showing expiration date.

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CPR Certification:

When does your CPR Certification expire?

ATTACH HERE a copy of the FRONT of your CPR CARD showing expiration date.

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ATTACH HERE a copy of the BACK of your CPR Card.

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Skills Verification Form:

ATTACH HERE a copy of your current EMR Skills Competency Verification Form.

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Confidentiality/Policy & Protocols:

I understand that it is my responsibility to maintain confidentiality of patient medical information. In addition, I understand as a certified Emergency Medical Responder in Yolo County I am responsible to know and adhere to all of their Policies & Protocols.


If you need to submit any further documentation for your application, please email us at: yemsa@yolocounty.org

Be sure to include your name & phone # in the email.


Application Fees:

A non-refundable application fee must be paid in order to process an application. Online applications can only be paid using a credit card and the card number will be encrypted for security purposes when submitted.

*​American Express is not accepted.


Will your Employer be paying for your Application Fee?

Re-Certification EMR Application Fee is $35.00. There is a $25.00 late fee for applications turned in the same month they expire (between 0-30 days).

Applications turned in the month before they are due are not considered late.

Credit Card Billing Address:


By submitting this information, I hereby authorize YEMSA to charge my credit card in the amount noted above.


Affirmations & Signature:


I hereby certify under penalty of perjury that all information on this application is true and correct to the best of my knowledge and belief, and I understand that any falsification or omission of material facts may cause forfeiture on my part of all rights to EMR certification in the State of California. I understand all information on this application is subject to verification, and I hereby give my express permission for this certifying entity to contact any person or agency for information related to my role and function as an EMR in the State of California.

Choose how to sign

Once all your information and documentation is received and verified, then your application will be processed normally within ten (10) business days.

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