Fillable Public Safety Registration Form (Nicolet Area Technical College)

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Public Safety Registration Form (Nicolet Area Technical College)

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File type: PDF

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Public Safety Registration Form
Please Print
__________________________________________
First Name
______
MI
__________________________________________
Last Name
____________________________________
Nicolet Student ID # or Social Security #
______________________________________________________________
Home Mailing Address
Office Use Only
_______________________________
______________________________________
City
_________
State
________________
Zip Code
__________________________
Phone - Home
__________________________
Phone: Cell Work
__________________________
County of Residence
__________________________
Township/Village/City of Residence
_______/_______/_______
Date of Birth
Email Address(Required for receiving certificate of completion)__________________________________________________________________Gender: Male Female
THE FOLLOWING INFORMATION IS FOR STATE REPORTING PURPOSES. INFORMATION PROVIDED WILL NOT AFFECT COURSE ADMISSION.
Ethnicity: Are you Hispanic or Latino (regardless of race)? Yes No
Race: (Check all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White
Name of Last High School Attended __________________________________________________________ City/State ____________________________________________
Highest Grade Completed ________ Year of High School Graduation/GED/HSED _______________
Highest Credential Earned: No Credential GED HSED HS Diploma Some college (postsecondary credit) Short-term diploma 1-year diploma
2-year diploma Associate degree Associate Degree + additional credential Baccalaureate Higher than baccalaureate
Fire Department (All students MUST Provide) ____________________________________________________________________
Class Section Dates Days Time City Building/Room Fee Sr Fee
FEES ARE DUE WITH REGISTRATION; *STUDENTS SPONSORED BY A
QUALIFYING FIRE DEPARTMENT NEED NOT SEND PAYMENT
* Senior Fees for person age 62+ are available for Continuing Education classes only
Total Fee:
PAYMENT METHOD Check/Money Order (Payable to Nicolet College) MasterCard Visa Discover
If participant is under age 18, please sign below.
Must be signed by parent or legal guardian.
I give permission for my son/daughter to enroll in
the above class(es) at Nicolet College.
____________________________ ________
Signature Date
Card Account Number _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ Expiration Date: _ _ / _ _
Verification Code: _________ (from signature line on back of credit card)
MAIL TO:
Nicolet College
Attn: Public Safety
PO Box 518
Rhinelander, WI 54501
publicsafety@nicoletcollege.edu
For More Information Call: 715.365.4600 or 800.544.3039 ext. 4600
$
$
$
Completed Registration Forms may be emailed to publicsafety@nicoletcollege.edu
Billing Address of Card (if different from above):
_______________________________________________________
_______________________________________________________
Public Safety Registration Form
Please Print
Nicolet College
STATE-SPONSORED FIRE CLASS
Payment Agreement
1. For students who are members of a fire department, the State of Wisconsin MAY
reimburse Nicolet College for tuition and materials fees for the courses listed below.
Book fees are excluded from reimbursement and students are responsible for payment of
book expenses.
2. Upon successful completion of each course, IF the student meets the academic and
attendance requirements, Nicolet College will be reimbursed by the State of Wisconsin.
3. Students must demonstrate all competencies and practical skills set forth by JPRs
(Job Performance Requirements), pass all written tests with 70% or better, attend 80% of
classes, and make up any work missed as determined by instructor. Each class must be
completed in its entirely.
4. If you do not pass the class or meet the other minimum requirements, Nicolet College
will bill you directly for all course fees.
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Public Safety Registration Form (Nicolet Area Technical College)

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Completed 9 October 2020

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