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Fire/Rescue Continuing Education Registration Form
Con Ed Course Title*  
Fill in course name
Course Section #  
Class Start Date:*  
Class Section # (refer to schedule on webpage)*  
Important: Please enter a valid email address. All registration details and future communication will be sent to this address.
After submitting your registration, you will receive a confirmation email for your records.
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 Fire/Rescue/EMS/Law Enforcement Dept. Affiliated with:*  
Status:  
Paid
Volunteer

Posistion:*  
Name of Chief/Director  
Contact Number for Chief/Director  
Electronic Signature
Students must be at least 18 years of age to enroll in Public Safety classes. Those under 18 must submit a Concurrent Enrollment Form each semester they are enrolled in a public, private, or homeschool, until their 18th birthday. To request this form, please contact the Continuing Education Office at (336) 694-8052.

By signing below, I certify that I am at least 18 years of age and understand that any unpaid balance with Piedmont Community College may affect my enrollment in this course.
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. Optional, sign if authorized.
Signature:  
Date:  
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