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EMS Pre-Registration Form - September
EMS Pre-Registration Form - September
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Last 4 Digits of SS#
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Last Name
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First Name
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Home Address
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Phone Number (Day)
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Phone Number (Night)
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E-mail Address
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Gender
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Employment Status
Employed
retired
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NC Resident
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Race
White - Non-Hispanic Origin
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Select Agencies you are a member of
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Law Enforcement
EMS
Fire
Rescue
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Agency Name (Agency Currently Holding your Certification)
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Job Title and/or Rank:
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Agency Address
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Courses Offered
"Oops Up Side Your...." Head Trauma - 09/15
"Step On A Crack..." Spine Trauma- 09/15
"Pump Up The Volume" ECHMO - Critical Care Topic
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Terms of Agreement
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Yes
By checking this box I do hereby attest that the information contain within the online registration form to be accurate and that my position places me within NCAC .203(5) (A) or (C) for fee exemption. I also In consideration for the opportunity to participate in the Southwestern Community College training program of 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 the risk 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 not to sue Southwestern Community College, its employees, whether full or part-time, paid or unpaid, it administrators directors and agents, for any death, property damage or loss, which I may sustain as a direct or indirect result of participation in the above referenced training program.
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