terry wadsley - carteret community college community college 3505 arendell street, morehead city, nc...

Carteret Community College 3505 Arendell Street, Morehead City, NC 28557‐2989

“Education for Life”

Tele: (252) 222‐6000

www.carteret.edu

October 02, 2017

To: EMT Program Applicant

From: Terry Wadsley, AAS, Paramedic

CE EMS Coordinator

Carteret Community College

Reference: CCC EMT Program Interest

Dear Prospective EMT Program Applicant:

Thank you for your interest in applying for admission to Carteret Community College’s, Corporate and Community Education Division’s EMT Program. The purpose of this information is to help you in completing your records for application and to explain the method of selecting students for the program.

The EMT at Carteret Community College (CCC) is accredited by the North Carolina Office of EMS and is approved by the North Carolina Community College System. The CCC EMT Program meets the current standards of the National EMT education standards. In addition, the program is consistent with the National EMS Education Agenda for the Future.

The EMT Program is the foundation of pre-hospital care and introduces the student to the world of pre-hospital medicine. The EMT Program is one semester and is taught in the spring of each year. This course introduces basic emergency medical care. Topics include preparatory, airway, patient assessment, medical emergencies, trauma, infants and children, and operations. Upon completion, students should be able to demonstrate the knowledge and skills necessary to achieve North Carolina State or National Registry EMT certification.

Graduates of this program may be eligible to take state and/or national certification examinations. Employment opportunities include providers of emergency medical services, fire departments, rescue agencies, hospital specialty areas, industry, educational and government agencies.

Terry Wadsley, AAS, Paramedic

Terry Wadsley

CE EMS Coordinator


3505 Arendell St.

Morehead City, NC 28557

tel. (252) 222-6029

fax (252) 222-6263

e-mail: [email protected]

http://www.carteret.edu/


mailto:[email protected]



Tele: (252) 222‐6000

www.carteret.edu

CCC EMT PROGRAM (Fall 2018)

Explanation of EMT Program Entry Requirements

EMT Program Admission Requirements:

The EMT Program accepts 24 students for continuing education (CCED).

CCED: EMT Program

There is no application fee for the CCED EMT Program. You must meet the admission requirements for the EMT Program. If you

have any further questions contact Terry Wadsley, at 252-222-6029 or by email at [email protected].

You need to bring the following documentation to your orientation session:

Government Issued Photo ID

Copy of high school diploma or GED

You can work with the Academic Support Office at CCC to schedule any placement testing you need to meet

these requirements. The entry requirements mandated by the NC OEMS are as follows:

You must have a high school diploma or GED or place into a 11th grade reading level on the college’s placement test. o You must take and pass the Carteret Community Colleges placement test demonstrating competency in reading. o Entrance Test Scores

Reading placement into ENG 095 or completion of ENG 111 or equivalent.

EMS Program Application Process, Orientation and Registration Session The number of applicants accepted into the program is limited. We will accept students in order of received completed EMS Program

Application packets. The application approval process is printed on the checklist at the end of this letter. This is the same checklist

used to validate packets by the EMS Program Coordinator. You will be notified of you acceptance into the EMS Program during the

orientation session. Once you receive your EMS Program Acceptance letter you will then need to register for EMS classes at the end

of the orientation and registration session. Please bring all monies for all fees with you to the orientation and registration session

on January 08, 2018, Wayne West Room 119B

**Admission to the program is based on meeting all criteria on a first come, first served basis.**

EMT Program Entry Requirements

Each EMT Program accepts 24 students maximum, so the first 24 students to complete all the EMT Program entry requirements will be awarded seats in that section of the EMT Program Cohort class of 2018.

The following completed documentation is due at the orientation and registration session on January 08, 2018:

EMS Program Application.

Background Checks

o Criminal Background checks are required for all EMS Students by our clinical providers. o DO NOT GO TO THE SHERIFFS DEPARTMENT AND GET ONE AS THIS WILL NOT SUFFICE.

US Info Group Criminal Background Check (The US INFO Group version only).(will be done after registration)

Copy of government issued photo ID must be included with your application.

Copy of high school diploma or GED must be included with your application.

Admissions test scores or copies of your official college transcripts must be presented to validate entry requirements.

Payment for the course

o $180.00 Registration Fee (Can be waived with verification of department membership). o $.55 Student Insurance Fee (CAN NOT BE WAIVED). o $4.00 BLS Card Fee (CAN NOT BE WAIVED).

Government Issued Photo ID

A copy of your current driver’s license is required for all students as proof of age and identity. Example of acceptable forms of ID:

NC Driver’s License or NC ID card.

Military ID.



mailto:[email protected]



Tele: (252) 222‐6000

www.carteret.edu

EMT Program Timeline and Program Costs Important Dates and Times: MANDATORY ORIENTATION IS January 08, 2018 at 18:00 IN THE WAYNE WEST BUILDING, ROOM 119B.

Start Dates: Jan 22, 2018 thru May 09, 2018, Carteret Community College

Class Times: EMS 4200 EMT Weekly on Monday & Wednesday.& First Saturday of each month. The remaining course work will be

completed on the Moodle section of the class.(Monday/Wednesday 18:00 – 22:00:00, Saturday 08:30 – 17:30)(lunch 12:00 – 13:00)

o Clinical: Students are required to complete a minimum of 24 hours of EMS field observational ride time. More information about clinical will be given during EMT Program Orientation.

Program Costs Pre-Course Fees: The US INFO Group Criminal Background Check is due on April 30, 2018

o Background Check $25.00

Registration Fee: $180.00 unless fee exempt, letter from department required. (Due at Registration)

Student Insurance Fee: $.55. (Due at Registration)

CRP Card Fee: $4.00 (Due at Registration)

Text Books: Emergency Care and Transportation of the Sick and Injured. 11th ed. Package is REQURED) & Basic Life Support for Healthcare Providers: 2016 Guidelines available in book store

Clinical Uniform and Supplies: See Attached CCC Paramedic Program Uniform Order Form. DO NOT PURCHASE ANY UNIFORM/EQUIPMENT UNTIL YOU HAVE ATTENDED THE ORIENTATION SESSION.

Physical and Mental Requirements of an EMS

The field of EMS can be both physically and emotionally stressful. This medical history form is designed to encourage the applicant to reflect on his or her current health status, include a personal immunization record, and have a physical examination by a physician. Applicants can expect to lift 50 pounds frequently with no maximum, do climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, feeling, talking, hearing, and seeing on a frequent basis. All of these activities may need to be performed in any type of environment – indoors or outdoors. In addition to the physical demands of the job, applicants may need to deal with challenging emotional, ethical and/or spiritual issues.

EMT Student Medical Requirements

The nature of EMS may include exposure to blood/body fluids and disease-causing organisms. Immunizations must be current in order to attend clinicals, a required part of the class.

This is a list of immunizations you will be required to present proof of: 1. Complete Tuberculin Screen Form 2. Rubella Vaccine or Titer (3 day measles) 3. Rubeola Vaccine or Titer (5 day measles, hard measles, red

measles) 4. Parotitis Vaccine or Titer (Mumps)

5. Tetanus and Diptheria Adult Vaccine (Td)

(current with past ten (10) years) 6. Hepatitis B Vaccine Series of (3) or Titer required 7. Varicella Vaccine Series of (2) or Titer (Chicken Pox)

required 8. Flu shot is required during flu season (September to

March each year)

EMS Program Entrance Requirement Checklist

Below are the steps for EMS Program Admission.

EMS Program Application Government Issued Photo ID

Copy of Admissions Test Scores Official College Transcripts submitted to Registrar

_____ High School Diploma or GED Attend Orientation Session





Tele: (252) 222‐6000

www.carteret.edu

Background Checks

FACT SHEET ON LEGAL ISSUES

Criminal Background checks are required for all EMS students by our clinical providers. National Criminal Background Checks are completed through a contract provider. DO NOT GO TO THE SHERIFF’S DEPARTMENT AND GET ONE AS THIS WILL NOT SUFFICE.

State Felony Statement:

1. Do you, as the person accepting responsibility by signing this form, have charges pending or have a conviction for a felony or misdemeanor other than a minor traffic violation or a judicial finding of eligibility for treatment in lieu of conviction (even if expunged or sealed)?

2. Have you committed any act in another state that, if committed in North Carolina, would be applicable to caption (1.) listed above?

If you answered “YES” to any of the above questions, please read on:

Actual certification to practice EMS within North Carolina is regulated by the North Carolina Office of EMS and the North Carolina Medical Care Commission. This body needs to evaluate all candidates for certification who answer “YES” to the above questions. The North Carolina Office of EMS will evaluate candidates ONLY upon successful completion of an EMS training program.

National Registry Felony Statement:

1. Do you currently engage in the illegal use of controlled substances, alcohol, or other habit forming drugs or chemical substances?

2. Have you committed fraud or material deception in applying for, or obtaining a certification to practice issued under North Carolina Statutes?

If you answered “YES” to any of the above questions, please read on:

If an individual has answered “YES” to any of the above questions. He/she must submit documentation to the National Registry office that fully describes the offense, copies of relevant court documents, disposition, and current status prior to receiving approval to sit for the National Registry examination. Prospective EMT or Paramedic students can request a review by the National Registry.

In the letter, the prospective student should state that he/she plans to enter an EMS education program and requests permission to sit for the examination upon successful completion of the EMS education program. The decision at this level allows the student to sit for testing only.



EMS PROGRAM APPLICATION

CARTERET COMMUNITY COLLEGE

MOREHEAD CITY, NORTH CAROLINA 28557 Phone (252) 222-6082 PLEASE PRINT OR TYPE

EMERGENCY MEDICAL SERVICES PROGRAM APPLICATION

Application for Acceptance

Please check one EMT-Basic (EMT-B Continuing Education) EMT-Paramedic (EMT-P Continuing Education)

Paramedic Diploma (D45340) , AAS in EMS (A45340, 2 Yr. Degree), AAS in EMS (A45340B Bridging Degree) Disclaimer: Completing this form does not guarantee entry into any EMS program. Specific program requirements must be met prior to acceptance.

PERSONAL INFORMATION

_P NC OEMS P Number

Complete Name (Last) (First) (Middle)

Present Mailing Address Street, Apt., or Box Number

City

State

Zip

County

Date of Birth Month/Day/Year

Home Phone

Cell Phone

E-Mail Address

EDUCATION

Highest Level of Formal Education: GED High School Adult High School College Certificate Associate Degree Bachelor’s Degree

Master Degree or Higher Date of Completion Certificate/Degree _

North Carolina EMS Certification Yes No (If yes, include copy of card)

If Yes, Please List EMT Certification Level Exp. Date

National Registry EMT Yes No (If yes, include copy of card)

If Yes, Please List Certification Level Date

AHA Healthcare Provider I do not have a CPR card

ARC Professional Rescuer

ASHI Professional CPR

CPR Expiration Date

(include copy of card)

Driver’s License Number and State and expiration date

(include copy of driver’s license)

Are You Currently Working in EMS?

Yes No

Agency or Department

Approximate Hours Worked Per Week

CRIMINAL BACKGROUND AND DISABILITIES STATEMENT

HAVE YOU EVER BEEN CONVICTED OF A CRIME? ARE YOU CHARGED WITH OR ON PAROLE/PROBATION FOR ANY CRIME?

YES NO IF YES, PLEASE EXPLAIN AND ATTACH ANY SUPPORTING DOCUMENTS

DO YOU HAVE ANY PHYSICAL OR LEARNING DISABILITIES IN WHICH YOU REQUIRE REASONABLE ACCOMMODATIONS?

YES NO IF YES, PLEASE EXPLAIN AND ATTACH COPY OF THE DISABILITY DETERMINATION, (ACCOMMODATIONS MUST BE APPROVED BY CCC COMPLIANCE OFFICER)

REFER TO THE APPLICATION INFORMATION FOR SPECIFIC DETAILS REGARDING ENTRANCE REQUIREMENTS. PLEASE REMEMBER THAT IT

IS THE STUDENT’S RESPONSIBILITY TO ACCOMPLISH THE ADMISSION REQUIREMENTS.

I certify that I have read and understand the enclosed application information. I also certify that the above information is correct and complete to the best of my knowledge and belief. I understand and agree that misrepresentation, falsification or omission of material fact may be cause for rejection of my application, or for

termination after acceptance into the EMS program.

Applicant Signature X Date of Application

For Office Use Only

EMS Credential _

AHA HCP CPR

HSD/GED Gov. Issue ID

PLACMENT TEST: reading

writing

math

CCC EMS Program 11/13/2014

Carteret Community College “Education for Life”

3505 Arendell Street, Morehead City, NC 28557-2989 Tele: (252) 222-6000

www.carteret.edu

October 02, 2017

To: Carteret County Public Safety Department Chiefs and Training Officers

From: Corporate and Continuing Education Division


Reference: Verification of Department Affiliation for Fee Exemption

This form will be used to verify eligibility of approved department personal for fee exemption in

courses sponsored by the Corporate and Continuing Education Division or Carteret Community

College.

Instructions

• To verify a single individuals department fill out section 1.

• To verify an entire departments status of fee exemption attach a current department roster

and fill out section 2.

Section 1

I verify that is a member of

Department in good standing as of / _/ _.

Officer Name:

(Please Print)

_, Officer Signature:

Title: , Phone Number:

(Please Print) (Please Print)

Section 2

I verify that the attached roster is a true list of Departments membership

roster as of / _/ .

Officer Name:

(Please Print)

_, Officer Signature:

Title: , Phone Number:

(Please Print) (Please Print)

Attach a copy of the roster to this form. An Equal Opportunity Educational Institution Serving the Community

without regard to Race, Creed, Sex, National Origin or Disability



3505 Arendell Street, Morehead City, NC 28557-2989

Education for Life”

Tele: (252) 222-6000

www.carteret.edu

1

1

2 4 4

4 4

EMT Students please return the following immunization verification to your instructor

along with a copy of you immunization records.

Student Name: ID Number:_ Date:

Part 1: Required vaccinations by age STUDENTS 17 YEARS OF AGE AND YOUNGER

DTP or Td Polio Measles Mumps Rubella

3 3 2 2 1

STUDENTS BORN IN 1957 OR LATER AND 18 YEARS OF AGE OR OLDER

DTP or Td Polio Measles 2,3

Mumps Rubella

3 0 2 2 1

STUDENTS BORN BEFORE 1957

1 4


3 0 0 0 1

STUDENTS 50 YEARS OF AGE AND OLDER

1


3 0 0 0 0

Part 2: Evidence of the following vaccinations according to the Do you currently have any of the following symptoms?

1) Polio vaccine (Student age 17 or and younger 2013) YES NO

2) Rubella vaccine or Titer (3 day measles) YES NO

3) Rubeola Vaccine or Titer (5 day measles, hard measles, red measles) YES NO

4) Parotitis Vaccine or Titer (Mumps) YES NO

5) Tetanus and Diptheria Adult Vaccine (Td) current with past ten (10) years YES NO

6) Flu shot recommended during flu season* YES NO

7) Varicella Vaccine (series of 2) or Titer (Chicken Pox) is recommended* YES NO

8) Hepatitis B Vaccine Series or Titer** YES NO

9) Annual TST (TB) skin test (current within past 90 days or NEG Questionnaire) YES NO

*Recommended immunizations/vaccinations and are just that recommended. You should discuss the risks and benefits of the immunizations/vaccinations with your health care provider. **Hepatitis B (HPV-B) is a highly communicable blood bone pathogen. Health care works are at great risk for exposure to this disease. If you opt not to be

vaccinated for HPV-B you will have to sign a waiver before you can participate in clinical. Please note many EMS agencies will NOT hire an EMT who has not been vaccinated against HPV-B due to the risk of contracting the disease.

Instructor Name Printed:

Instructor Signature: Date:

An Equal Opportunity Educational Institution Serving the Community

without regard to Race, Creed, Sex, National Origin or Disability



3505 Arendell Street, Morehead City, NC 28557-2989


Tele: (252) 222-6000

www.carteret.edu

Please complete the following TB screening questionnaire and return it

with your physical form to your instructor.

Name: ID Number:

Date:

Part 1: Tuberculosis Risk Questionnaire

1) Were you born outside the USA in one of the following parts of the world: Africa, Asia, Central

America, South America or Eastern Europe YES NO

2) Have you traveled outside the USA and lived more than one month in one of the following parts of the

world: Africa, Asia, Central America, South America or Eastern Europe YES NO

3) Do you have a compromised immune system such as from any of the following conditions:

HIV/AIDS, organ or bone marrow transplantation, diabetes, immunosuppressive medicines (e.g.

prednisone, Remicade), leukemia, lymphoma, cancer of the head or neck, gastrectomy or jejeunal

bypass, end-stage renal disease (on dialysis), or silicosis?

YES NO

4) Have you ever done one of the following: used crack cocaine, injected illegal drugs, worked or

resided in jail or prison, worked or resided at a homeless shelter, or worked as a healthcare worker

in direct contact with patients?

YES NO

5) Have you ever been exposed to anyone with infectious tuberculosis? YES NO

Part 2: Tuberculosis Symptom Questionnaire

Do you currently have any of the following symptoms?

1) Unexplained cough lasting more than 3 weeks. YES NO

2)

Unexplained fever lasting more than 3 weeks

YES

NO

3)

Night sweats (sweating that leaves the bed clothes and sheets wet)

YES

NO

4)

Shortness of breath

YES

NO

5)

Chest pain

YES

NO

6)

Unintentional weight loss

YES

NO

7)

Unexplained fatigue (very tired for no reason)

YES

NO

An Equal Opportunity Educational Institution Serving the Community without regard

to Race, Creed, Sex, National Origin or Disability


Emergency Medical Science Program

Effective 2017

I. EMS Program Re-Admission Procedure

A. If a student does not successfully complete the first semester of the Program, the student

MUST re-apply to the Program for the next academic year.

B. Student Conduct Violation

i. A student that is dismissed from the College due to a violation of the College’s

Student Conduct Policy is not eligible for re-admission to the Program.

ii. A student that is dismissed from the Program due to a violation of the NC EMS

Practice Act may not be eligible for re-admission to the Program.

1. The student must be cleared of all allegations made by the NC OEMS Disciplinary

Board in order to be eligible for re-admission.

C. Re-admission is not guaranteed due to the competitive admission process. D. Refer to

the published admission requirements for fall 2014.

II. Program Re-Entry Procedure

A. Definitions of Withdrawal

i. Involuntary Withdrawal

1. Academic

a. A student that does not achieve a grade of “C” or better for courses in the

curriculum plan with an EMS, MED, or BIO prefix.

2. Physical / Mental Health Issues

a. A student that is withdrawn from the Program due to the inability to

meet program requirements.

3. Student Conduct Violation

a. A student that is dismissed from the College due to a violation of the

college’s Student Conduct Policy is not eligible for re- admission to the

Program.

b. A student that is dismissed from the Program due to a violation of the NC

EMS Practice Act may not be eligible for re- admission to the Program.

i. The student must be cleared of all allegations made by the NC

OEMS Disciplinary Board in order to be eligible for re-entry.

ii. Voluntary Withdrawal

1. Physical / Mental Health

a. A student that withdraws from the Program due to physical or mental

health issues.

2. Personal

a. A student that withdraws from the Program due to personal reasons (e.g.

financial, child-care issues).

B. Involuntary Withdrawal

i. Academic

1. If a student wishes to be considered for re-entry the next academic year, the student

must:

a. Submit an updated EMS Program Application to the Program

Curriculum Area Coordinator (CAC).

b. Schedule a meeting with the EMS CAC to discuss any re-entry criteria that was

listed in the academic dismissal letter, if one was issued.

c. Submit a current Student Medical Form.

d. Repeat the criminal background check and drug screen. e. Present

proof of current AHA BLS certification.

2. Re-entry in the program is not guaranteed.

a. Re-entry is only possible if there is a space available in the next year’s class.

b. Students will be notified of their re-entry status at least 30 days prior to the date

of requested re-entry.

3. A student may only re-enter through this procedure once. If the student is unsuccessful

at this attempt, counseling will be provided to explore other career opportunities.

ii. Physical / Mental Health

1. If a student wishes to be considered for re-entry the next academic year, the student

must:

a. Submit an updated EMS Program Application to the Program


b. Schedule a meeting with the EMS CAC to discuss the criteria for re-entry.

c. Submit a current Student Medical Form.

d. Repeat the criminal background check and drug screen. e. Present

proof of current AHA BLS certification.

f. Provide documentation from a licensed healthcare provider stating that the

health issue is now resolved or is currently being managed successfully.

i. This documentation is in addition to the Student Medical Form that

is required of all students in the program.

2. Re-entry in the program is not guaranteed.

a. Re-entry is only possible if there is a space available in the next year’s class.

b. Students will be notified of their re-entry status at least 30 days prior to the date

of requested re-entry.

3. A student may only re-enter through this procedure once. If the student is unsuccessful

at this attempt, counseling will be provided to explore other career opportunities.

iii. Student Conduct Violation

1. A student that is dismissed from the College due to a violation of the college’s Student

Conduct Policy is not eligible for re-admission to the Program.

2. A student that is dismissed from the Program due to a violation of the NC EMS

Practice Act may not be eligible for re-admission to the Program.

a. The student must be cleared of all allegations made by the NC OEMS

Disciplinary Board in order to be eligible for re-entry.

C. Voluntary Withdrawal

i. If a student withdraws from the program voluntarily, the student may be considered for re-

entry the next academic year by fulfilling the following requirements:

1. Submit an updated EMS Program Application to the Program


2. Schedule a meeting with the EMS CAC to discuss the criteria for re- entry.

3. Submit a current Student Medical Form.

4. Repeat the criminal background check and drug screen.

5. Present proof of current AHA BLS certification.

6. A student who withdraws from the program for physical or mental health reasons

will be required to provide documentation from a licensed healthcare provider

stating that the health issue is now resolved or is currently being managed

successfully.

a. This documentation is in addition to the Student Medical Form

that is required of all students in the program.

ii. Re-entry in the program is not guaranteed.

1. Re-entry is only possible if there is a space available in the next year’s class.

2. Students will be notified of their re-entry status at least 30 days prior to the date of

requested re-entry.

iii. A student may only re-enter through this procedure once. If the student is unsuccessful at

this attempt, counseling will be provided to explore other career opportunities.

D. Re-Entry Timeline

i. If a student does not re-enter the next academic year, the student must apply for re-admission.

1. Re-admission is not guaranteed due to the competitive admission process.

2. Refer to the published admission requirements for the applicable academic year.

Carteret Community College “Education for Life” 3505 Arendell Street, Morehead City, NC 28557-2989 Tele: (252) 222-6000

EMS Program Readmission Policy

Readmission to the EMS Program

Student who are unable to complete the EMS Program with their assigned cohort and wish to

reapply for admission into a new cohort must meet the following guidelines.

• Complete an update Carteret Community College application as per admissions policy.

• Complete an updated EMS Program Application and submit it the EMS Program CAC.

• Schedule a meeting with the EMS CAC to discuss any readmission criteria that was listed in the academic dismissal letter if one was issued.

o Students who are removed for violation of the academic integrity are not eligible for readmission to the EMS Program.

o Students who violate the NC EMS Practice Act must be cleared of all allegations by the NC OEMS Disciplinary Board prior to reinstatement.

I have received a copy of the Carteret Community College EMS Program Readmission Policy. I have read and understand this policy.

Student Name Print Student Signature Date

Instructor Name Print Instructor Signature Date Sales Tax

Grand Total

CARTERET EMS PROGRAM

Student Online Criminal Background Check/Drug Screen Request Procedure

The cost for your Criminal Background Check is a flat fee of $25. Required for all EMS Students

The cost for a 12 Panel Drug Screen is $47. Required for EMT-P Students ONLY

a. Go to: www.usinfogroup.com

b. Click on the University/Community Colleges Student Access picture box.

c. Enter the following USERID and Password.

School User ID: CCCEMS

School Password: student

d. Click on “Secured Login”

e. Follow the instructions to request your criminal background and/or Drug Screen:

Please note you must have an active email address to complete the ordering

process. f. If you are ordering a drug screen you will receive an email with a drug screen

registration form attachment. Print the form and go to the drug testing facility

location listed on the form.

Drug screens must be completed no later than 48 hours from the date the

on-line registration is created. The expiration date and time is notated at the

top of the form. g. Your Criminal Background Check/Drug Screen will be processed upon

successful processing of your credit/debit card.

h. Upon completion of your Criminal Background Check/Drug Screen, you will

receive an email from USInfoGroup notifying you of the completed request(s).

i. To view your completed request(s), follow the steps above for a, b, c and d.

Follow the instructions for returning students.

j. Upon completion of your request, an electronic copy will be forwarded to your

clinical site(s) if they are known.

If you do not have access to a computer please call (919) 570-9861 and one of our customer

service representatives will be available to assist you.

Revised 11/13/2014

http://www.usinfogroup.com/


STUDENT REGISTRATION FORM Corporate & Community Education Contract # _________________

COURSE INFORMATION

1. 11.

Instructor

STUDENT INFORMATION

2. SSN: - - 12. Sex: (check one) 1-Male 2-Female

3. Name: 13. Race: (check one) 1-White 2-Black

3-Indian 4-Hispanic 5-Asian

4. Mailing Address: 14. Highest Grade Completed: or:(check one)

(--)GED Diploma (15)Associate Degree

5. City: (13)Adult High School (16)Bachelor's Degree

(14) 1 Year Voc Diploma (17)Masters Degree or higher

6. State: Zip:

7. Phone Number: Home: 15. Residence: State County Name

Work: 16. Vocation:

8. Birthdate: 17. Employment:(check one) (F)Full-time (1)Retired

(P) Part-time All students under 18 must complete a dual enrollment form to attend class.

(U) Unemployed

18. Employer:

9. Email Address: @

10. Student's Signature 19. Date

THIRD PARTY BILLING STATEMENT If prior authorization has not been received/given to CCC for the student's fees to be paid by a third party you must sign the following statement:

I agree to pay all charges associated with this class if my company refuses payment.

Signature

Company Name Who to Contact about payment Phone#


Corporate & Community Education COURSE RECEIPT

Payment:

Check

Cash

$ Registration Fee $ Insurance Fee $ Book Fee $ Supply Fee $ Donation to Dept $ Misc. Fee $ Total Received

Student Name:

Course Name Contract #

Received by: Date:

(Instructor's Signature- Only sign if money is received from this student)

terry wadsley - carteret community college community college 3505 arendell street, morehead city, nc...

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