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Surry Community College EMS Program
Emergency Medical Responder (EMR)
Class Pre-registration Form
Name
*
First
Last
Email
*
Confirm
Phone
*
###
-
###
-
####
Please enter the best number to reach you.
Mailing Address
*
City / Town
*
State of Residence
*
NC
VA
Other
Zip Code
*
Select course that you are pre-registering for
*
Please select
EMR April 5, 21 - June 2, 21 M/W, 6p-10p Center for Public Safety in Mt Airy
Select the course that you are pre-registering for here. They are arranged by date.
If you do not see the course you are looking for then the dates have not been set or the course is currently in progress.
Are you at least 18 years old?
*
Yes
No
Date of Birth
*
MM
/
DD
/
YYYY
Do you have a High School Diploma or GED?
High School Diploma
GED
Neither
Are you a member of a NC emergency services organization that qualifies for a tuition waiver?
*
Yes
No
Unsure
Agency affiliated with
Enter the name of your department or agency here. If you are not affiliated with an emergency services agency please enter None.
Rank or Title with Agency
Select...
FF
LT
ENG
CAPT
CHIEF
RT
EMTP
EMT
MR
Other
Other Rank or Title with Agency
Tuition Waiver
Select...
CEVFR Volunteer Firefighter
CEPFR Paid Firefighter
CEVRS Volunteer Rescue
CEPRS Paid Rescue
CEEMS Paid EMS
CEPLW Paid Law Enforcement
CECVP Civil Preparedness
Employment
Select...
Employed 1-10 hrs per week
Employed 11-20 hrs per week
Employed 21-39 hrs per week
Employed 40 or more hrs per week
Unemployed - not seeking employment
Unemployed - seeking employment
FT Full-time employed
PT Part-time employed
Retired
Highest Grade Completed
Select...
9
10
11
12
GED
AHS
1 yr. Voc. Diploma
2 yr. Associate Degree
4 yr. Bachelors Degree
Masters Degree / Higher
Gender
Male
Female
Demographic information is gathered for statistical purposes only.
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