CE Paramedic Program Application

* Last Name:

Middle Initial:

Address:

City:

State:

Zip:

* Phone Number:

Cell Phone Number:

* Email Address: Must be a valid email address

Prerequisites

High School Diploma or High School Equivalency? Diploma GED Other-Specify in comment

NC or National Registry EMT Certified? Yes No

NC EMT "P" Number or National Registry Number:

Have you completed a college-level English Course (ENG 111 or equivalent) or taken a placement test within the last 12 months? Yes No Other-Specify in comment

Have you completed a college-level Math Course (MAT 143 or equivalent) or taken a placement test within the last 12 months? Yes No Other-Specify in comment

Successful completion of a Human Anatomy and Physiology Course. EMS-3000 BIO-163 Other-Specify below

Specify the Anatomy and Physiology Course you have completed.

Applicant Statements

Are you affiliated with an EMS Agency, Volunteer Fire Department, or Rescue Squad? Yes No

If you are affiliated with an agency, list the agency/department here:

Have you read the Paramedic Program Course Requirements and reviewed the online checklist? Yes No

Have you submitted the following documents to the Program Director via email?
Send required documents to Scott Shew at gshew4054@stanly.edu

*Copy of High School Transcripts or Diploma Yes No

*Copy of Current NC or NR EMT Credential Yes No

*Copy of Current NC Driver's License Yes No

Applicant Comment:

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