09/2018
Emergency Medical Services Continuing Education Registration
Complete this form and mail or fax with payment to:
Durham Technical Community College
525 College Park Road, Hillsborough, NC 27278
Fax: 919-536-7297 / Phone: 919-536-7238 x4205
ems@durhamtech.edu
• Payment or payment authorization is required at time of registration and must
be received before the first class.
• Receipts or confirmations will not be sent for payments that are faxed or mailed.
• The refund policy can be found at
durhamtech.edu/continuing-education/cancellations-and-refunds
Last name: First name: MI:
Address: City: State: ZIP:
County: Please check if this is a new address or change in information.
Home: ( ) Business: ( ) Ext.: Cell: ( )
Colleague ID #: (assigned by college if new student) Date of birth:
Email address: Social Security number:
Public safety agency: Position or job title:
Highest education level completed
Non-graduate
(highest grade completed)
GED
High school diploma
Adult high school
Vocational diploma
Associate’s degree
Bachelor’s degree
Master’s degree or higher
Gender
Female Male
Race (check all that apply)
American/Alaska native
Asian
Black/African-American
Hawaiian/Pacific Islander
Hispanic/Latino
Non-Hispanic/Non-Latino
White
EMS P# (if applicable):
Employment status
Full time (40 or more hours/week)
Part time (39 or fewer hours/week)
Retired
Unemployed (not seeking)
Unemployed (seeking)
Course Number Course Title Location M T W Th F Sa Su Start Time End Time Start Date End Date Cost
By checking this box, I certify I am 18 years or older and not enrolled in high school (a release form from your high school is required otherwise) and also
authorize Durham Tech to release my grades to my employment agency or the credentialing agency as needed for certification purposes only.
Student signature
Date
$ Registration fee paid received from student or
$ Registration fee billed to sponsoring agency
$ Books Other Check #: Bank:
Credit card #: AMEX DISCOVER MC VISA
Cardholder name: Exp. date: (MM/YY) Credit card security #:
My signature attests that I am actively affiliated with the public safety agency listed and that I hold the job classification indicated.
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