(Fire College) Continuing Education Registration Form

Continuing Education Registration Form
Important: The information collected on this form will be kept confidential and used only for legitimate College purposes including registration for courses, maintenance of student and permanent record (transcript) and reports required by the State of North Carolina and the federal government.

Unsigned or Incomplete forms will not be processed.
Course CID#*
Enter this number :
Course Title*
Enter this title :
Registration Fee:
Full Name*
Address*
Apartment #
City*
Zip*
State*
County*
DCCC Student ID Number
Date of Birth:*

MonthDayYear
Date
Age*
Race:*

American/Alaska NativeBlack or African AmericanHawaiian/Pacific IslanderAsianWhite
Ethic:*

Hispanic/LatinoNon-Hispanic/Latino
Gender:*

MaleFemale
Home Phone:
Please enter a valid phone number.
Cell Phone:*
Please enter a valid phone number.
Employment:*

Retired and not employedUnemployed-not seeking employmentUnemployed-seeking employmentEmployed 1 - 10 hours per weekEmployed 11 -20 hours per weekEmployed 21- 39 hours per weekEmployed 40 or more hours per week
Highest level of education completed (1-12):
Or Check one:

High School GraduateAdult High School DiplomaGED GraduatePost High School Vocational DiplomaAssociate's DegreeBachelor's DegreeMaster's Degree or Higher
If you are fee exempt for this course, YOU MUST indicate the agency affiliation or YOU will be responsible for payment!
Please select type of agency:*

Firefighter Public AgencyFirefighter Vol AgencyEMS Rescue Vol AgencyElem/Secondary School EmployeesTelecommunicator/DispatcherLaw Enforcement OfficerEMS/Rescue Public AgencyNamed in EOP PlanEmergency ManagementDetention OfficerDACJJ Certified Officer
Agency Affiliation*
By signing this form below you are verifying that you are actively affiliated with the public safety agency above and that you hold the job classification marked.
Student Signature:*

Clear
Email Address:*
example@example.com
Date*

MonthDayYear
Date
Should be Empty: