EMS Instructor Methodology Interest Form

EMS Instructor Methodology Interest Form

Please complete this form and submit it to the DDCC EMS Program. If you need to fax a document, please use 336-249-9053 or Mail to Leann Pate (PSS 112) Davidson-Davie Community College PO Box 1287, Lexington, NC 27293. If you need to reach her by email please use Leann_Pate@davidsondavie.edu or phone 336-249-8186 ext 6328..
EMS Methodology Prerequisites
- Be currently credentialed as an EMT, AEMT, Paramedic.
- Possess a High School Diploma, or High School Equivalency certificate, and verify or demonstrate their ability to read and write at 11th-grade proficiency level.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
If you’re affiliated with a Public Safety Agency, please provide the full department name (If no affiliation type "No") :*
Have you ever registered for an EMS class @ DDCC?*

YesNo
Which program are you more so interested in?*

April 10, 2025 to June 6, 2025 (On Campus Dates 5/9/25 9a-5p & 6/6/25 9a-5p)July 10, 2025 to September 5, 2025 (On Campus Dates 8/9/25 9a-5p & 9/5/25 9a-5p)October 2, 2025 to November 21, 2025 (On Campus Dates 10/30/25 9a-5p & 11/21/25 9a-5p)
Students wishing to enroll in the EMS Instructor Methodology course must have an active credential as an EMT, AEMT, Paramedic. Please include your certification or registry number below.
NC OEMS or NR Number*
Expiration Date of NC OEMS or NR Certification:*

MonthDayYear
Date
Upload copy of valid certification:*

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Required Materials for Submission:

If you need to complete the TABE or CASAS test for placement in English, Leann Pate will give you that information at time she contacts you to discuss your Interest Form.
Please submit the following documents to show eligiblity into the program, please submit all documents at the same time if possible.
- High School Diploma (or equivalent)
**OR**
- College Credit for English (transcript grade of C or higher)
**OR**
- TABE/CASAS Test Reading Score of Level 11.0
Upload your proof of eligibility here:*

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*DDCC Admin Only*
Additional Eligibility Upload

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Email Communication

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Comments
Before approving check the Student's Prohibited list:

https://docs.google.com/spreadsheets/d/1Pq8PCP_UplGq-hSVT6S72e6fLoINGR94/edit?usp=sharing&ouid=116830508952068736967&rtpof=true&sd=true
Approved by:

Leann PateDustin GardnerChelsea WellsSam O
Approved to Register:

Yes, Email Confirmation Sent to StudentUpdate (No, EMAIL)Student is Prohibited to Register
Date Approved:

MonthDayYear
Date
Comments for Student File:
EMS Program Eligibility List:

THE FORM IS AUTOMATICALLY FILLED OUT

https://docs.google.com/spreadsheets/d/1hHgLW0Zsd0FSkoJxZtb5i3bukFBnsbzKkCWy46KofO8/edit?usp=sharing
Should be Empty:

EMS Instructor Methodology Interest Form

Required Materials for Submission: