Fire / Rescue / Emergency Management Demographics Form Fire, Rescue, & Emergency ManagementFire, Rescue, & Emergency Management Home Continuing Education Home Emergency Medical Services 2019 Burke Fire Academy 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.Today's Date Date Format: MM slash DD slash YYYY 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) Black or African American (BL) 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:* Date Format: MM slash DD slash YYYY 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 week(FT) Full Time(PT) Part-TimeTraining Type*Please select from the following:FireRescueEMSLaw EnforcementHighest 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)Name of Department or Agency*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:*Please enter your first name, middle initial, and last name to serve as your signature for this form.NameThis field is for validation purposes and should be left unchanged.