College of the Great Smoky Mountains - Southwestern Community College, serving Jackson, Macon, and Swain Counties and Cherokee/ Qually Boundary
» Back to SCC Home
» Public Safety Training  » About Us   » EMS Home

Emergency Medical Science Program

Application for Admission • Continuing Education

Instructions:
1. Answer all questions on this form on your screen. This is secure since it does not transmit to the internet.  
2. Print  
3. Sign and date  
4. Mail application and appropriate documentation to: Public Safety Training Complex, Southwestern Community College, 225 Industrial Park Loop, Franklin, NC 28734, USA  
Attach the following: EMT-I and Above Only
Current BLS Certification Current TB Skin Test
High School Diploma Hepatitis B Immunization
GED Current Tetanus Vaccine
Childhood Immunization EMT-Basic Credentials

I am applying for: EMT-Basic EMT-Basic - Online EMT-Intermediate

Start Date:
Location:
Last Name :
First Name :
Middle and/or Maiden Name :
Mailing Address :
City : State : Zip :
Social Security No.       Birthdate :
Day Phone No. : Night Phone No. :
NC Resident: Yes No

Highest Grade Completed : (Attach Appropriate Documentation)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
GED

Colleges Attended :
Degree Earned :
Current Certificates or Training (Please attach appropriate documents) :

Are you a member of a fire, rescue, EMS, or law enforcement department? Yes No
If yes, which department?

I certify that all information given in this application is accurate to the best of my knowledge, and I agree to observe all rules and regulations of Southwestern Community College and the EMS Training Program.

 

Signature________________________________ Date Signed _______________

Return Application and appropriate documentation to:
SCC Public Safety Training Complex
152 Industrial Park Road
Franklin, NC 28734
828.369.0591 (Office)
828.369.2428 (Fax)

FOR OFFICE USE ONLY
Date Received: ________________
Application Complete: Yes / No
Items Missing: __________________
_______________________________

Click here to print this page.
 
 Last updated 2/12/09


 
Southwestern Community College • 447 College Drive • Sylva, NC 28779
828·339.4000 or 800·447·4091
fax 828·586·3129