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Advanced EMT
FALL 2020
CANDIDATE REVIEW FORM
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INSTRUCTIONS:
Read and complete Steps 1-3 of the Registration Checklist in the Advanced EMT Information Packet.
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STEP 4: Download this form, complete PART 1: STUDENT INFORMATION, and save the file as a PDF. Email
the following items to the Admissions Office staff for application to the Advanced EMT program:
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Registration Form PDF (Part 1 completed)
Copy of your government-issued photo ID (PDF or JPEG)
Affiliation Letter (if affiliated with NC Fire/Rescue/EMS agency)
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STEP 5: You will be contact regarding your application status. Admitted students will be registered for the
class. Payment is due by the deadline listed in the table below.
COURSE SECTION
DATES
DAYS/TIMES
PAYMENT DEADLINE
EMS-4300-01
(51272)
October 12, 2020
February 10, 2021
Rotating Schedule:
Odd Weeks: M/T 8:30am-4:30pm
Even Weeks: W/Th 8:30am-4:30pm
Friday, October 9, 2020
at 12pm
a.
PART 1: STUDENT INFORMATION
FULL NAME (first/middle/last): _______________________________________________________________
STREET ADDRESS: _________________________________________________________________________
CITY/STATE/ZIP: _______________________________________ COUNTY: ____________________
HOME PHONE: ____________________________ CELL PHONE: ___________________________________
EMAIL: ___________________________________________________
AFFILIATION: If affiliated, please check the appropriate box and list the complete name of the organization.
(NOTE: If affiliated, applicant must submit a letter from the department verifying active affiliation and good standing.)
Firefighter (Vol) LE Officer
Firefighter (Paid) EM Personnel
EMS Responder (Vol) Telecommunicator/Dispatch
EMS Responder (Paid) Detention Officer
AGENCY: __________________________________ JOB TITLE: ______________________________
STUDENT SIGNATURE: ______________________________________ DATE: _________________
Your signature on this document indicates that the information included in your registration packet is correct
and that you have read and understood the EMT-Initial program information document.
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PART 2: APPLICATION CHECKLIST STUDENT ID: __________________
**This section will be completed by RCC Admissions Office staff**
Notes
(Staff Use Only)
Item
Verification
(Staff Use Only)
RCC application on file with the Admissions Office ________ Verified by Admissions Staff
Official high School/GED transcript on file with
Admissions Office
________ Verified by Admissions Staff
Copy of government-issued photo ID
(i.e., driver’s license or passport)
________ Verified by Admissions Staff
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
________ Credit for DRE 096, 097, 098
and DMA 010-030
________ RISE Tier 1 Math & English
Copy of current EMT certification on file ________ Verified by Admissions Staff
If affiliated with NC Fire/Rescue/EMS agency:
Applicant is required to provide a letter from the
department confirming they are on the roster and in good
standing with that department.
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________ Letter provided
________ Not affiliated with agency
Admissions Office Staff: _________________________________________ Date: ___________________