Fire / Rescue / Emergency Management Demographics Form Fire, Rescue, & Emergency ManagementFire, Rescue, & Emergency Management Home Emergency Medical Services CompanyThis field is for validation purposes and should be left unchanged.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 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence:*Out-of-StateAlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnetHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenbergMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanleyStokesSurrySwainTransylvaniaTyrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYanceyPrimary Contact Phone:*Work Phone:Date of Birth:* 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.
