Wilderness EMS Summit Online Registration << Back to WPCC Fire / Rescue /Emergency Management Home Register for the Wilderness EMS Summit, September 15-16, 2018 Students must register and pay any registration fees two business days 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. 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 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 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 / 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 weekHighest 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. 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 nameClass InformationCANCELLATION 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 OnlyWPCC 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 boxesVolunteer or Paid (choose one):VolunteerPaidState or Local / County Agency (choose one):StateCounty AgencyAgency 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 CourseCourse Title*Section NumberBeginning Date* Date Format: MM slash DD slash YYYY Course Cost*Add additional courses:Add another courseSecond CourseClass TitleSection NumberBeginning Date Date Format: MM slash DD slash YYYY Class CostThird CourseClass TitleSection NumberBeginning Date Date Format: MM slash DD slash YYYY Class CostPhoneThis field is for validation purposes and should be left unchanged.