Wilderness EMS Summit Online Registration

Students must register and pay any registration fees two business days prior to the start date of the class.

Required Information

Information 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. The Social Security Number is required for federal & state reports, and certification classes.

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/African American (BL)
Caucasian (WH)
Hawaiian/Pacific Islander (HP)

WPCC Student ID

(If known)

Mailing Address:*

Street Address City State ZIP Code

County of Residence:*

Primary Contact Phone:*

Work Phone:

Date of Birth:*

If you are 16 years of age and still enrolled in high school, you must certify by placing your initials in the box that you are in good academic standing and are making satisfactory academic progress toward graduation prior to being registered for this class.

Employment / Education

The 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*

Highest Level of Education Completed:*

Date Last Attended High School*

Month/Year (MM/YYYY)

Certification of Accuracy

By submitting this online registration form, I certify to the best of my knowledge that the information given is true and complete. Further, I understand and agree that my electronic signature is the legal equivalent of my manual signature.

I certify to the best of my knowledge that the information given is true and complete. Further, I understand that by submitting this information via electronic transmission that I acknowledge the following: I do not have any outstanding balances with Western Piedmont Community College. I understand that I cannot register into a class that meets at the same time of another WPCC class for which I am registered. I understand that if I falsify any information on the demographics information above, or on any future registration forms, my certification will be eliminated. I understand and agree that my electronic signature is the legal equivalent of my manual signature. Permission is granted to release appropriate course information to certifying agencies.

Electronic Signature:*

First name, middle initial, last name

Class Information

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.

Public Safety and Training Programs: Fee Waived Classes Only

WPCC reserves the right to ask for verification of fee exemption eligibility from the student and/or agency.

Please note that to be eligible for fee exemption, the course/s you are registering for must be directly related to job performance or necessary to continue certification. If this information is not populated in its entirety, there will not be a fee waiver and the student will be responsible for payment. The student's registration will be flagged to disallow further registrations until payment in full is made or the required fee exemption information is received by the Workforce and Professional Development Department, Department Affiliation (ie.: Fire, Rescue, Law Enforcement):

For Fire, Rescue, Law Enforcement, Etc. Information below is REQUIRED, Check appropriate boxes

Volunteer or Paid (choose one):

Volunteer
Paid

State or Local / County Agency (choose one):

State
County Agency

Agency Name:

Please enter the complete agency name- No abbreviations.

Job Title:

Students must register and pay any registration fees two business days prior to the start date of the class.

First Course

Course Title*

Section Number

Beginning Date*

Course Cost*

Add additional courses:

Add another course

Second Course

Class Title

Section Number

Beginning Date

Class Cost

Third Course

Class Title

Section Number

Beginning Date

Class Cost

Phone

This field is for validation purposes and should be left unchanged.

Register for the Wilderness EMS Summit (#63436), September 17-18, 2022

Students must register and pay any registration fees two business days prior to the start date of the class.

Required Information

Employment / Education

Certification of Accuracy

Class Information

Public Safety and Training Programs: Fee Waived Classes Only

Students must register and pay any registration fees two business days prior to the start date of the class.

First Course

Second Course

Third Course