Fillable Public Safety Registration Form Fire/Law/EMS Courses Only (Haywood Community College)

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Public Safety Registration Form Fire/Law/EMS Courses Only (Haywood Community College)

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Public Safety Registration Form
Fire/Law/EMS Courses Only
Student Information
Shaded Areas Required
Last Name
First Name
M. I.
Maiden Name
Mailing Address
City
State
Zip Code
County
Primary Phone
Secondary Phone
SSN (Public Safety Fee Waiver Requirement)
Date of Birth (MM/DD/YYYY)
Male
☐
Female
☐
Are you a full time NC resident?
Yes
☐
No
☐
High School Name
Retired (R)
Unemployed – not seeking (UN)
Unemployed Seeking (US)
Employed 1 – 10 Hours (E1)
Employed 11 – 20 Hours (E2)
Employed 21 – 39 Hours (E3)
Employed 40 or more hours per week (E4)
Ethnic Origin
Hispanic/Latino
Non-Hispanic
Select One or More Races:
American/Alaska Native
Asian
Black or African American
Hawaiian/Pacific Islander
White
Check the highest grade completed
1
☐
2
☐
3
☐
4
☐
5
☐
6
☐
7
☐
8
☐
9
☐
10
☐
11
☐
12
☐
High School Graduation Date _______________
GED
Adult High School
1-Year Vocational Diploma
Associates Degree
Bachelor’s Degree
Master’s Degree or Higher
Course Information
Course Number
Course Title
Cost of Class
Fees
Dates
Times (Specify AM or PM)
Location
Days (Check all that apply)
M
Tu W Th
F Sa Su
Fee Waiver Information
Agency Name – No Abbreviations
Job Classification
Firefighter Volunteer Agency EMS Responder Volunteer Agency Emergency Management Personnel
Firefighter County/State/Municipal Agency EMS Responder County/State/Municipal Agency Named in EOP
Telecommunicator/Dispatcher LE Officer Sponsored BLET Detention Officer
DACJJ Certified Officer: Specific Title with DACJJ _____________________________________________________________________________
Other ____________________________________________________________________________________________________________________
Please Flip Over and Complete the Remainder of the Registration on the Back
Prefer not to disclose
Public Safety Registration Form
SIGNATURE: DATE:
By signing this form, student agrees the information above is true and accurate and the legal residence given for tuition purposes
is as shown. Student agrees to abide by the HCC Policies and Procedures and the Student Code of Conduct. Unprofessional
behavior can place student’s participation in jeopardy and will be viewed as grounds for dismissal. A complete guide to conduct
can be viewed here: http://www.haywood.edu/policies_and_procedures/policy/6/7 Student agrees to allow HCC to publish
photographs, video footage and personal information pertaining to news releases or other publications or media normally
considered to be that of a two-year college unless a disclaimer has been filed with the Director of Enrollment Management.
I agree that my signature attests that I am actively affiliated with the public safety agency listed and that I hold the job
cl
assification indicated.
Supplemental Student Accident Insurance
As a registered student of a Continuing Education
Date: ___________ Amount Enclosed $________
Course you have the option of purchasing
Check Money Order Cash
Supplemental Student Accident Insurance 3rd Party Billing (Authorization Required)
for $1.25 per semester.
TERM I Jan-1-May15
TERM II May 16-Aug 15
TERM III Aug 16-Dec. 31
Yes, I would like to purchase Supplemental Student
Accident Insurance
No, I would not like to purchase Student Accident
Insurance
***All registration forms should be mailed, faxed or returned to the main campus in person. If you choose to email
this form
be aware that email is not secure and subject to North Carolina Public Records Law. This registration form
does not guarantee your enrollment into the class. Some Public Safety courses have external agency requirements that
may not be listed ***
For more information on HCC’s Public Safety Courses please visit our website at:
https://www.haywood.edu/instruction/workforce-continuing-education/public-safety
Contact Us
Law Enforcement Training Emergency Medical Services
Krystal Shuler Fred Clontz
828-565-4103 828-565-4548
General Information
Shannon Brown
828-627-4669
ssbrown@haywood.edu
HCC-emstraining@haywood.edu HCC-lawenforcementtraining@haywood.edu
Fire/Rescue Training
Dee Massey
828-565-4247
HCC-firetraining@haywood.edu
Please check all information before mailing. Course
number must be accurate to ensure proper placement in
class. Send check or money order made payable to
Haywood Community College (no cash, please) to:
Mail-In Registration
Haywood Community College
185 Freedlander Drive
Clyde, NC 28721
(828) 627-4505
Fax: (828) 627-8396
E-mail: HCC-WC
E@haywood.edu
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Public Safety Registration Form FireLawEMS Courses Only (Haywood Community College)

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Completed 26 July 2020

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