________________________ Student ID #
2020 Emergency Medical Services - Paramedic
Candidate Review Form
PLEASE TYPE OR PRINT CLEARLY.
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED!
NAME _____________
_____________________________________________________________________________
FIRST MIDDLE LAST
SIGNATURE _________________________________________SOCIAL SECURITY NUMBER
______- ____ -______
ADDRESS_________
_________________________________________________________________________________
CITY _______________________ STATE _____ ZIP ___________ COUNTY OF RESIDENCE ______________________
TELEPHONE HOME ________-________-___________ WORK ________-________-___________
E-MAIL ADDRESS ________________________
_______________________________________________ (Please Print)
DATE OF BIRTH _____\_____\______ GENDER Male Female HISPANIC/LATINO ORIGIN? YES NO
PLEASE CHOOSE
ONE OR MORE RACIAL CATEGORIES TO DESCRIBE YOURSELF
Black/African American Native American or Alaska Native
Asian White
Native Hawaiian or Other Pacific Islander
PLEASE CHECK
ONE OF THE FOLLOWING:
Current high school student High school graduate Adult high school or GED
EMPLOYMENT: Retired Part-time Full-time Unemployed Unemployed Seeking Employment
EMPLOYER ____________________________________ OCCUPATION _______________________________________
AFFILIATION: My signature above attests that I am actively affiliated with the NC public safety agency listed and that I
hold the job classification indicated. Please check the appropriate box and list the complete name of the organization
you represent.
Firefighter (Vol) LE Officer
Firefighter (Paid) EM Personnel
EMS responder (Vol) Telecommunicator/Dispatcher
EMS responder (Paid) Detention Officer
AGENCY: ______________________________________________ JOB TITLE: ________________________________
Minimum Admissions Requirements Check Sheet
DO NOT FILL OUT THIS PAGE!
To be completed by the Admissions Staff in the Whitcomb Student Center.
Notes
(Staff Use Only)
Item
Verification
(Staff Use Only)
Placement test scores or waiver on file
Must have credit for DRE 096, 097, 098 and DMA 010, 020, 030
OR RISE Tier 1 Math and Tier 1 English
____Verified by Admissions Staff
High School Transcript or equivalent on file
____Verified by Admissions Staff
Credit for EMS-3000 (Basic Anatomy & Physiology) or higher
NOTE: A grade of "C" or higher
in BIO 163, BIO 168 & BIO 169, or
BIO 165 & BIO 166 satisfies this requirement
(Applicants may be enrolled in EMS-3000, BIO 163, BIO 169, or BIO 166 in Spring 2020.
Student must finish the course before clinicals begin.)
____Verified by Admissions Staff
Copy of Driver’s License or Government issued ID on file
____Verified by Admissions Staff
Your signature on this document indicates that the above information is correct to the best of your knowledge.
Student Signature: ___________________________________________________ Date: ________________
Signature of Admissions Staff completing form: ________________________________ Date: ____________
Important Dates, Deadlines, and Payment Information
Paramedic Class Dates
Application Deadline
Payment Deadline
October 5, 2020 - December 15, 2021
September 25, 2020
by 12pm
October 2, 2020
by 12pm
*Contact Admissions at (336) 342-4261 ext. 2333 for more information*
Copy o
f current EMT certification on file
____
Verified by Admissions Staff
Applicant has a current RCC Application on file
in the Admissions Office
____Verified by Admissions Staff
**Total cost of course is $726, plus textbooks... $366 plus textbooks if member of NC Fire/Rescue Agency**
M/W 6pm-10pm
Every other Saturday 8am-5pm
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