Wilderness EMS Summit Online Registration << Back to WPCC Fire / Rescue /Emergency Management Home Register for the Wilderness EMS Summit, September 23-24, 2017 Students must register and pay any registration fees two business days/48 business hours prior to the start date of the class.Required InformationInformation in this area is for record keeping purposes only and will not be used in a discriminatory manner. However, this information is required for federal reports, state reports and state certification. After registering for your class, this information will be destroyed.Name* First Last Middle Initial:Email Address:* Gender* Female Male Ethnic Origin:*(Check one)- If you select the NHS option, please complete the following RACE section: Hispanic (HIS) Non-Hispanic/Latino (NHS) Race:*Choose one Alaskan Native/American (AN) Asian (AS) Caucasian (WH) Hawaiian/Pacific Islander (HP) WPCC Student ID(If known)Mailing Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence:*Out-of-StateAlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnetHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenbergMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanleyStokesSurrySwainTransylvaniaTyrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYanceyPrimary Contact Phone:*Work Phone:Date of Birth:* Are you 16 years of age and still enrolled in high school?*YesNoIf you answered "Yes" above, you must certify by placing your initials in the box below that you are in good academic standing and are making satisfactory academic progress toward graduation prior to being registered for this class.*Employment / EducationThe following information is mandatory for ALL STUDENTS. If this information is not provided, the student can not be registered for requested class(es).Employment Status*(R) Retired(UN) Unemployed – Not Seeking Employment(US) Unemployed – Seeking Employment(E1) Employed – 1-10 hours per week(E2) Employed – 11-20 hours per week(E3) Employed – 21-39 hours per week(E4) Employed – 40+ hours per weekTraining Type*FireRescueEMSLaw EnforcementName of Department or Agency*Job Title*Highest Level of Education Completed:*123456789101112GED DiplomaAdult High School DiplomaVocational DiplomaAssociate DegreeBachelor's DegreeMaster's Degree or HigherDate Last Attended High School*Month/Year (MM/YYYY)Certification of AccuracyBy submitting this online registration form, I certify to the best of my knowledge that the information given is true and complete and agree that my electronic signature is the legal equivalent of my manual signature. Further, I understand that by submitting this information via electronic transmission that I acknowledge the following: 1) I do not have any outstanding balances with WPCC 2) I understand that I cannot register into a class that meets at the same time of another WPCC class for which I am registered and 3) I understand that if I falsify any information on any of the information above, I may be removed from the class. Permission is granted to release appropriate course information to certifying agenciesElectronic Signature:*First name, middle initial, last nameClass Information(If you are at least 16 years of age and still enrolled in high school, you must have a dual enrollment form signed by your school principal or approved designee to participate in this class.) CANCELLATION POLICY/REFUND POLICY: If WPCC cancels a class, the student will be notified. A one-hundred percent registration fee refund for Workforce and Professional Development classes shall be made upon request of the student if the student officially withdraws from classes at least one business day prior to the class start date. A seventy-five percent registration fee refund for Workforce and Professional Development classes shall be made upon request of the student if the student officially withdraws from classes prior to or at the 10 percent point of the class. Requests for refunds will not be considered after the 10 percent point. The refund policy does not apply to self-supporting classes. To officially withdraw from a class the student must request to be withdrawn from the class in person (special accommodations can be made for students who live outside of a 50 mile radius). A "Request for Refund" form can be obtained from the appropriate registration personnel located in the office of Records and Registration. Students must register and pay any registration fees two business days/48 business hours prior to the start date of the class.Class Name*Wilderness EMS SummitClass Beginning Date Class Cost*EmailThis field is for validation purposes and should be left unchanged.