Practical Exam Registration Form

Pee Dee Regional EMS, Inc.

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This form must be completed and submitted 14 days prior to the exam date for EMT and 21 days prior to the exam for AEMT and Paramedic! No Exceptions will be allowed: Practical Exam cost is $25.00 per skill station for the EMT and AEMT exams. The paramedic practical exam is $300.00 for the six stations: Please call (843) 662-5771 or email Beth@PDREMS.Com if you have questions.

PLEASE NOTE: If you need to repeat a basic skill and you are testing for an advanced level (AEMT or Paramedic) YOU MUST DO SO AT AN ADVANCED EXAM! Please call the office for the next scheduled advanced exam date.

* Indicates required field

Name *

First

Last

Middle Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

SC EMT Number *

Training Course Number (Issued for each course in CIS. *

If you do not know your course number it can be located by searching the CIS web site www.emspic.org/sc/go .If the course was conducted outside of SC please enter None

Last 4 of Social Security Number *

Date of Exam you are Registering for: *

NREMT PATT Authorization # *

Select One *

If registering for either AEMT or Paramedic Exam you MUST supply the PATT number issued by NREMT with this registration form. You must bring the PATT letter with you to the practical exam.

Skills Needed *

EMT Exam- Choose All That Apply *

Medical Assessment Trauma Assessment CPR/ AED Oxygen Administration BVM Ventialtion LMA Airway King Airway Bleeding Wounds & Shock Joint Immobilization Long Bone Immobilization Seated Spinal (KED) Supine Spinal (LSB)

AEMT Exam- Choose All That Apply *

Medical Assessment Trauma Assessment Respiratory Compromise LMA King IV Therapy IV Push medication Pediatric IO Supine Spinal (LSB) Seated Spinal (KED) Bleeding Wounds & Shock Long Bone Immobilization Joit Immobilization

Paramedic Exam- Choose All That Apply: *

Trauma Assessment Out of Hospital Scenario Dynamic Cardiology Static Cardiology Oral Station A Oral Station B

Submit