PUBLIC SAFETY STUDENT REGISTRATION FORM

Public Safety Registration ONLY
**Please use Legal Name when completing the form.**
Name: *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence: *
Primary Phone: ( )
Phone Type:

Home Cell Business
Other Phone: ( )
Phone Type:

Home Cell Business
Student ID or Last 4 of Social Security # *
Birthdate (mm/dd/yyyy): *

Month Day Year
Date
Email Address: *
example@example.com
Sex: (Check One) *

Male Female
Ethnic/Race: *

American/Alaska Native Hawaiian/Pacific Islander Asian Hispanic Black or African American White Asian/Pacific Islander
Current Employment Status: *

Retired Unemployed – Seeking 40 or more hours 21 – 39 hours 11 – 20 hours 1 – 10 hours
Education Level: (Check or enter the highest grade completed) *

Completed High School Adult High School Diploma GED® or High School Equivalency Diploma One-Year Vocational Degree Associate Degree Bachelor’s Degree Master’s Degree or Higher Never Attended Highest Grade Completed
Highest Grade Completed:
Occupation:
Employer:
Student Status:

New WCC Student Previous/Current Wcc Student
Course Information:
Class Title:
Semester:

Spring Summer Fall
Year:
Example: 2020
Class Start Date:

Month Day Year
Date
Class Time:
For Public Safety Courses ONLY
My signature attests that I am actively affiliated with the public safety agency listed and that I hold the job classification indicated.
Name of Public Safety Agency/Department/Team: *
Job Classification: *

Firefighter (Volunteer) Firefighter (County/State/Municipal) EMS Responder (Volunteer) EMS Responder (County/State/Municipal) Emergency Mgt. Personnel Named in EOP Telecommunicator/Dispatcher Law Enforcement Officer Detention Officer Sponsored BLET Other DACJJ Certified Officer Job Title:
DACJJ Certified Officer Job Title:
I hereby give permission to Wayne Community College & the NC Department of Community Colleges to release my grades to:

(Please initial on the line below for the appropriate agencies)
NC Department of Insurance Fire/Rescue Commission

Initial Clear
NC Criminal Justice’s Training and Standards Commission and/or NC Sheriff’s Commission

Initial Clear
Supplemental Student Accident Insurance SSA Ins: As a registered student of a Workforce Continuing Education Course you may purchase Supplemental Student Accident Insurance for $0.55 per semester.

Yes – I would like to purchase SSA Ins. NO – I would NOT like to purchase SSA Ins.
Student Signature:

Your signature indicates that all information is accurate, and you have read & understand the Refund Policy.
I certify the above information is true and accurate: *

Clear
Date: *

Month Day Year
Date
REFUND POLICY FOR WORKFORCE CONTINUING EDUCATION SERVICES COURSES
The refund policy for Continuing Education Services courses, as established by the N.C. General Assembly, allows a 75 percent refund, after the respective class begins, upon the request of the student if the student officially withdraws from the class prior to or on the 10 percent point of the scheduled hours of the class.

A 100 percent refund, shall be made if the student officially withdraws prior to the first day of class of the academic semester or term as noted in the college calendar. Also, a student is eligible for a 100 percent refund if the class, in which the student is officially registered is canceled due to insufficient enrollment.

There are no refunds for self-supporting classes. Under this policy, the college shall notify the student of the right to receive a refund at the time of official withdrawal.
Should be Empty:

Public Safety Registration ONLY

Course Information:

For Public Safety Courses ONLY

Student Signature:

REFUND POLICY FOR WORKFORCE CONTINUING EDUCATION SERVICES COURSES