Advanced EMT Program Interest Form

Advanced EMT Program Interest Form

Please complete this form and submit it to the DCCC EMS Program. If you need to fax a document, please use 336-249-9053 or Mail to Diane Hedgecock (PSS 112) Davidson County Community College PO Box 1287, Lexington, NC 27293. If you need to reach her by email please use Diane_Hedgecock@DavidsonCCC.edu or phone 336-224-4791
Today's Date

Month Day Year
Date
Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email
example@example.com
Phone Number

Area Code Phone Number
Have you ever registered for an EMS class @ DCCC?

Yes No
Please submit the following documents to show eligiblity into the program, please submit all documents at the same time if possible.

Drivers License

Successful completion of an EMT Program (EMT Card or P#)

High School Diploma (or equivalent)

College Credit for English (transcript grade of C or higher) **OR** TABE Test Reading Score of Level 12.0

College Credit for Math (transcript grade of C or higher) **OR** TABE Test Math Score of Level 12.0
Upload your proof of eligibility here:

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