Surry Community College EMS Program
Class Pre-registration Form
Please enter the best number to reach you.
City / Town
State of Residence
Select course that you are pre-registering for
EMT Basic January 7,2021 T/Th 6p-10 Center for Public Safety in Mt Airy
EMS 3000 A&P Sept 9 2020-Nov 4 2020 10a-3p 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?
Were you in the Spring 2020 EMT class in Mt Airy prior to COVID-19
Date of Birth
Do you have a High School Diploma or GED?
High School Diploma
Are you a member of a NC emergency services organization that qualifies for a tuition waiver?
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
Other Rank or Title with Agency
CEVFR Volunteer Firefighter
CEPFR Paid Firefighter
CEVRS Volunteer Rescue
CEPRS Paid Rescue
CEEMS Paid EMS
CEPLW Paid Law Enforcement
CECVP Civil Preparedness
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
Highest Grade Completed
1 yr. Voc. Diploma
2 yr. Associate Degree
4 yr. Bachelors Degree
Masters Degree / Higher
Demographic information is gathered for statistical purposes only.