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Fire/Rescue Continuing Education Registration Form
Con Ed Course Title*  
Fill in course name
Class Start Date:*  
Class Section # (refer to schedule on webpage)*  
Important: Enter a valid e-mail address. All correspondence will be sent to this address.
Registrant Information
First Name:*  
Middle Initial:  
Last Name:*  
Address Line 1:*  
Address Line 2:  
County (NC residents only)  
Zip Code:*  
Home Phone:*  
Cell Phone:*  
Male Female 

Date of Birth*  
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 Fire/Rescue/EMS/Law Enforcement Dept. Affiliated with:  

Select as Applies:  
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.
Enter first & last name
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.
Enter first & last name
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.
Optional, sign if authorized
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