Burke County Emergency Services Weekend Registration

Name(Required)

First Middle Last

County(Required)

City, State, Zip Code(Required)

Cell Phone(Required)

Work Phone

Home Phone

Date of Birth(Required)

Email(Required)

Employment Status:(Required)

(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 week

Highest level of education that you have COMPLETED (1-12):(Required)

Month / Year last attended High School:(Required)

Select Diploma or Degree Received:(Required)

(--) GED Diploma

(13) Adult High School Diploma

(14) Vocational Diploma

(15) Associate Degree

(16) Bachelor's Degree

(17) Master's Degree or Higher

If you are at least 16 years of age and still enrolled in high school, you must certify, by placing your initials below that you are in good academic standing and are making satisfactory academic progress toward graduation prior o being registered for this class.(Required)

Please list your 1st, 2nd and 3rd choice of classes. Please note that we will make all attempts to register you for the selected class choices; however; if the class/es are full or cancelled, we will automatically register you for the next listed choice.(Required)

PUBLIC SAFETY AND TRAINING PROGRAMS WPCC and/or the Compliance Office of the North Carolina Community College System reserves the right to ask for verification of fee exemption eligibility from the student and/or agency. If the information within this area is excluded, or not fully completed, the fee waiver will not be given and the cost of the class will be the responsibility of the student. If not paid, further registrations will be restricted until balance is paid in full.

FOR FIRE, RESCUE, LAW ENFORCEMENT, ETC. INFORMATION BELOW IS REQUIRED, CHECK APPROPRIATE BOXES(Required)

Volunteer

or Paid

State

or Local / County Agency

Department Affiliation (ir: Fire, Rescue, EMS) | Clearly Print Department / Agency Name - No Abbriviations:(Required)

By placing my initials below, I certify that I am listed on the official roster, in employment or volunteer services of the above agency.(Required)

Student Signature & Date(Required)

With my signature, I certify that the information provided on this registration form is true and accurate. The college has my permission to release pertinent information on the form to appropriate College staff and, in the event of an emergency or illness, I give permission for them to call a local physician. Please be advised that WPCC cannot register you for any class if you have an outstanding debt with the College. If this class is for certification, by affixing my signature above, I grant permission to release the appropriate course information to the certifying agency.

Chief Signature & Date

Fire, Rescue, & Emergency Management

Registration Form

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Burke County Emergency Services Weekend Registration

Fire, Rescue, & Emergency Management

Registration Form