Emergency Service Application
Class/Course Interest
Title of course you would like to register for:
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Anatomy & Physiology (EMS 316301)
Initial Emergency Medical Responder (EMR)
Initial Emergency Medical Technician (EMT)
Initial Paramedic
Community Paramedic
Community Paramedic Clinical Experience
Community Paramedic Skills Review
Community Paramedic AND Community Paramedic Clinical Experience
Continuing Education - EMR & EMT Level
Continuing Education - Paramedic Level
Refresher Course - EMR, EMT, Paramedic
*EMS Course - Other/Not Listed, Please list in the Additional Notes
Identification
Datatel ID# or SS#:
Confirm Datatel ID# or SS#:
Date of Birth:
Last Name:
First Name:
Middle Name:
Address
Street:
City:
State:
Zip Code:
County:
Contact Information
Telephone Home:
Telephone Work:
Telephone Cell:
Email Address:
Employment Information
Name of Employer:
Employment Status:
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Employed
Full-Time
Part-Time
Unemployed
Retired
Agency Information
Name of Rescue Agency:
Agency Status:
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Full-Time
Part-Time
Volunteer
Current Position:
Street:
City:
State:
Zip Code:
Other Information
Race:
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White
African American
Native American
Hispanic
Asian
Other
Education:
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High School
Adult High School
GED
1 Yr. Voc Diploma
Associate Degree
Bachelor Degree
Highest HS Grade Completed:
Last Year Attended HS:
Name of Last Highschool Attended:
State if other than NC:
I certify that I am a member of an emergency service organization (fire department, rescue squad, EMS, law enforcement, etc.) in the state of North Carolina.
Additional Notes or Questions: