EMT Academy Interest Form

EMT Academy Interest Form

Please complete this form and submit it to the Davidson-Davie EMS Program. If you need to fax a document, please use 336-249-9053 or Mail to Leann Pate (Brooks Rm# 206) Davidson-Davie Community College, PO Box 1287, Lexington, NC 27293. If you need to email her, please use Leann_Pate@davidsondavie.edu or phone 336-249-8186 ext 6328.
EMT STUDENT PREREQUISITES
1. 17 years of age on or before the official end date of the course

2. Possession of a high school diploma, high school equivalency or successful completion of an exam assessing basic reading comprehension skills at a minimum at the eleventh-grade 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"):*
Are you a current or previous student at Davidson-Davie Community College?*

YesNo
Which program are you more so interested in?*

Fall 2025 EMT Daytime Academy (M-Th 9a-11:30am)Fall 2025 EMT Night Academy (Tuesdays & Thursdays 6p-10p, with Occasional Saturdays 9a-6p)Fall 2025 EMT Hybrid Academy (Saturdays & Sundays 9a-6p)Fall 2025 EMT Daytime Academy- Davie Campus (M-F 9a-11:30am)
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 the 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.

Drivers License

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 GardnerSam OChelsea WellsOther
Approved to Register Status:

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:

EMT Academy Interest Form

Required Materials for Submission: