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Emergency Medical Services - CASWELL
  
Monthly Con Ed
GEMS
PALS Instructor 54392
EMT Aug 2025
AEMT Aug 2025
PEPP 54394
PTEP 54396
PEPL 54395
ACLS Instructor
CPR Instructor
Other

If Other, type in course title*  
Campus Location:*  
Class Start Date:*  
Class 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  
Status:  
Paid
Volunteer

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.
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.
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