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Emergency Medical Services / BLS - PERSON
  
Monthly Con Ed
BLS (CPR)
BBN
Other

If Other, type in course title*  
Campus Location:*  
Start Date:*  
End Date:*  
Important: Enter a valid e-mail address. All correspondence will be sent to this address.
E-Mail:*  
Registrant Information
First Name:*  
Middle Initial:  
Last Name:*  
Address Line 1:*  
Address Line 2:  
City:*  
State:*  
County (NC residents only)  
Zip Code:*  
Home Phone:  
Cell Phone:*  
Sex*  
Male Female 

Date of Birth*  
  
  
  
SSN*  
Colleges and Universities are asked by many, including the federal government, accrediting associations, college guides, newspapers, and your own college/university communities, to describe the racial ethnic backgrounds of our students and employees. In order to respond to these requests, we ask you to answer the following two questions:
Do you consider yourself to be Hispanic/Latino?*  
Yes No 

Ethnic Origin:*  
Educational Experience
Highest Educational Level Completed*  
Employment Status
Employment Status*  
Name of EMS/Fire/Law Enforcement Department Affiliation (If Applicable)  
Status:  
Paid
Volunteer

Role*  
N/A
Firefighter
First Responder
EMT
Paramedic
LEO

Name of Chief/Director  
Contact Number for Chief/Director  
Electronic Signature
I understand that having any unpaid balances wtih Piedmont Community College may affect my enrollment in this class.
Signature:*  
Enter first & last name
Date*  
 
Students enrolling in Public Safety classes must be at least 18 years of age and must provide a Concurrent Enrollment Form each semester he/she is enrolled in a public/private/home school until his 18th birthday. Contact the Continuing Education Office at (336) 694-8052 for the Concurrent Enrollment Form.
Signature:*  
Enter first & last name
Date*  
 
Photography & Quote Release: I hereby authorize Piedmont Community College to use my image and/or quotes for any use the College deems appropriate in the promotion and marketing of PCC. I fully discharge PCC from any and all claims, monetary or otherwise, arising out of the image or quote.
Signature:  
Optional, sign if authorized
Date:  
Student Education Records Acknowledgement Form
First Name*  
Middle Initial*  
Last Name*  
Date of Birth*  
  
  
Student ID (if known)  
Address*  
City*  
State*  
Zip Code*  
 
Under the Family Educational Rights and Privacy Act (FERPA) 20 U.S.C. § 1232g and Leon’s Law, SL 2025-46, the Piedmont Community College is permitted to disclose information from your education records to your parent(s)/legal guardian(s), without consent, if they claim you as a dependent for federal tax purposes.

I acknowledge to the extent allowed under the Family Educational Rights and Privacy Act (FERPA) and Leon’s Law,


(1) My education records will be provided to my parent(s)/legal guardian(s) as long as the parent/legal guardian has not opted out of receiving the education records.


(2) My education records will be provided to the school administrators and school counselors at the school in which I am dually enrolled.
 
Student Signature*  
Date  
 
Parent(s)/legal guardians(s) Contact Information
Parent First Name*  
Last Name*  
Address*  
City*  
State*  
Zip Code*  
 
Parent First Name  
Last Name  
Address  
City  
State  
Zip Code  
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