EMS Re-Credentialing Process

*First Name:

*Last Name:

Middle Name:

*Date-of-Birth:

Address:

City:

State:

Zip Code:

*Phone Number:

*Email Address:

Certification Level

*NCOEMS Provider Number (P-number):

NC Credential Expiration Date:

Department Agency Affiliation:

Student ID:

Comments (500 characters limit):

Acknowledgement
Under the Family Educational Rights and Privacy Act (FERPA) 20 U.S.C. § 1232g and Leon’s Law, SL 2025-46, 91AV is permitted to disclose information from your education records to your parent(s)/legal guardian(s), without consent, if you are under 18 years of age and they claim you as a dependent for federal tax purposes.

* I acknowledge, to the extent allowed under the Family Educational Rights and Privacy Act (FERPA) and Leon’s Law,
(1) My education records will be provided to my parent(s)/legal guardian(s) as long as the parent/legal guardian has not opted out of receiving the education records.
(2) My education records will be provided to the school administrators and school counselors at the school in which I am dually enrolled.

91AV

EMS Re-Credentialing Process

91AV

EMS Re-credentialing Process