2008 Online Registration Form

To pre-register, complete this application for each participant and mail with a check of $10.00 per person (non-refundable) made payable to:
SOUTHWESTERN COMMUNITY COLLEGE    225 Industrial Park Loop · Franklin, NC 28734    (Please register by August 15, 2008)	Registration is not complete until money has been received. There will be a $25 fee for any returned checks

* = Required fields
(*)Social Security No.	(*)Last Name	(*)First Name	Mid Initial

(*)Address: Street/PO Box/Route	(*)City	(*)State	(*)Zip	(*)County of Residence

(*)Date of Birth (mm/dd/yyyy)	Male Female	White Black Indian Asian Hispanic Other

(*)Phone Number - Home	Phone Number - Work	Phone Number - Cell
(*)E-Mail Address

Check Highest Grade Completed: GED 9 10 11 12 13 14 15 16 17 18 19 20 Employment: Employed Full-Time Employed Part-Time Unemployed Employer: Fire Dept/Rescue Squad/EMS/Law Enforcement Dept: (*)Agency Name

	Select the courses from the drop down menu that you would like to take in priority order.   You MUST choose 4 courses. » See List of courses and descriptions
1st choice	Select course Session 1 Hazardous Materials Operations Session 2 Personal Protective Equipment Session 3 Portable Fire Extinguishers/Foam Fire Streams Session 4 Salvage/Overhaul Session 5 Ladders Session 6 Fire Hose, Streams & Appliances Session 7 Ventilation Level I & II Session 8 Fire Alarms & Communications Session 9 Building Construction Session 10 Emergency Medical Care Session 11 Fire Control Session 12 Rescue Technician VMR Session 13 RT Combination Series Session 14 Pumps: Water Supply Session 15 Introduction of Pumps Session 16 Wildland Fire Behavior Session 17 NIMS 100/700 & 200 Session 18 Introduction to Fire Fighting/Rescue Session 19 Personal Vehicle Driver, Emergency Response – SkidCar Session 20 GPS/Land Navigation Session 21 Air Medicine Today
2nd choice	Select course Session 1 Hazardous Materials Operations Session 2 Personal Protective Equipment Session 3 Portable Fire Extinguishers/Foam Fire Streams Session 4 Salvage/Overhaul Session 5 Ladders Session 6 Fire Hose, Streams & Appliances Session 7 Ventilation Level I & II Session 8 Fire Alarms & Communications Session 9 Building Construction Session 10 Emergency Medical Care Session 11 Fire Control Session 12 Session 12 Rescue Technician VMR Session 13 RT Combination Series Session 14 Pumps: Water Supply Session 15 Introduction of Pumps Session 16 Wildland Fire Behavior Session 17 NIMS 100/700 & 200 Session 18 Introduction to Fire Fighting/Rescue Session 19 Personal Vehicle Driver, Emergency Response – SkidCar Session 20 GPS/Land Navigation Session 21 Air Medicine Today
3rd choice	Select course Session 1 Hazardous Materials Operations Session 2 Personal Protective Equipment Session 3 Portable Fire Extinguishers/Foam Fire Streams Session 4 Salvage/Overhaul Session 5 Ladders Session 6 Fire Hose, Streams & Appliances Session 7 Ventilation Level I & II Session 8 Fire Alarms & Communications Session 9 Building Construction Session 10 Emergency Medical Care Session 11 Fire Control Session 12 Session 12 Rescue Technician VMR Session 13 RT Combination Series Session 14 Pumps: Water Supply Session 15 Introduction of Pumps Session 16 Wildland Fire Behavior Session 17 NIMS 100/700 & 200 Session 18 Introduction to Fire Fighting/Rescue Session 19 Personal Vehicle Driver, Emergency Response – SkidCar Session 20 GPS/Land Navigation Session 21 Air Medicine Today
4th choice	Select course Session 1 Hazardous Materials Operations Session 2 Personal Protective Equipment Session 3 Portable Fire Extinguishers/Foam Fire Streams Session 4 Salvage/Overhaul Session 5 Ladders Session 6 Fire Hose, Streams & Appliances Session 7 Ventilation Level I & II Session 8 Fire Alarms & Communications Session 9 Building Construction Session 10 Emergency Medical Care Session 11 Fire Control Session 12 Session 12 Rescue Technician VMR Session 13 RT Combination Series Session 14 Pumps: Water Supply Session 15 Introduction of Pumps Session 16 Wildland Fire Behavior Session 17 NIMS 100/700 & 200 Session 18 Introduction to Fire Fighting/Rescue Session 19 Personal Vehicle Driver, Emergency Response – SkidCar Session 20 GPS/Land Navigation Session 21 Air Medicine Today
	If the course requested is full, students will be registered for the next available course.

(*) By checking this box I do hereby attest that the information contained within this online registration form to be accurate.

Liability Waiver

STUDENT WARNING
Participation in a public safety-training program involves risks of personal injury and property damage. The public safety training programs at Southwestern Community College have been designed in accordance with all applicable Federal, State and regulating agency standards in an effort to provide the degree of training necessary and to minimize the risks of injury and damage. However, inherent in the operation of such programs are risks associated with improper use of equipment and facilities, defective or malfunctioning equipment, and improper conduct by the participants in the program.

Prior to participating in each training activity, participants will be instructed in the proper use of any equipment and facilities. Participants shall be responsible for following correct procedures and safety precautions.

ASSUMPTION OF RISK AND RELEASE
In consideration for the opportunity to participate in the Southwestern Community College training program of the Western North Carolina Area Fire/Rescue/EMS and Law Enforcement College, the undersigned participant agrees to comply with all rules, regulations, procedures and safety precautions established by Southwestern Community College in connection with the above referenced training program and the use of the equipment and facilities associated with it. Furthermore, I acknowledge the existence of risks connected with this program, agree to assume such risks and agree to accept responsibility for any injuries, illness, death and property damage sustained by me in the course of participating in this program.

I hereby agree for myself, my heirs, assigns, executors and administrators to release and consent to not sue Southwestern Community College, its employees, whether full or part time, paid or unpaid, its administrators, directors and agents, for any losses, and to hold them harmless for any liability for any injuries, death, property damage or loss, which I may sustain as a direct or indirect result of participation in the above referenced training program.

(*) By checking this box, I acknowledge that I have read and understand the Liability Waiver and that I sign it voluntarily.

A High School Release Form must be completed for students 16 or 17 years old.
» Download and print a copy of the form. Signatures of the high school principal and President of SCC must be obtained.