EMS & Fire Registration Form

Timer

--:--

* = required field

Some content may be updated based on selection

EMS & Fire Department Registration Form

Toll-free: 1-800-472-4554 Web: www.morainepark.edu

*Submitting this registration form does not guarantee placement into selected classes.

Check COURSE SEARCH to verify there are seats available in the course(s) you are requesting.

*Registrations are processed in 1-2 business days by Enrollment Services on a first come first served basis.

Same day form processing cannot be guaranteed.

*Enrollment is based on class availability and payment (if required) of tuition and fees.

________________________________________________________________

Step 1 - Demographic Information

Last Name:

First Name:

Middle Initial:

Former Names:

Gender:

Student ID #:

Social Security Number:

Date of Birth (mm/dd/yyyy):

U.S. Citizen?

Visa Status:

If Other, please list:

Are you Hispanic or Latino (that is Cuban, Mexican or Puerto Rican, South or Central American regardless of race)?

Check one or more from the following that bests describes your race:

Are you a high school graduate?

If you did not graduate, did you complete a GED/HSED?:

Date of HSED/GED Completion:

Step 2 - Address/Phones

Please check here if your address has changed since the last time you attended Moraine Park Technical College.

Mailing Address:

City:

State:

Zip Code:

County:

Legal Resident of:

Primary Phone:

Phone Type:

Secondary Phone:

Phone Type:

Is MPTC allowed to text updates?

E-mail Address:

Do you have a Fire Certification Number?

Step 3 - Registration for Classes/Exams
Please enter the five-digit course registration number (CRN), class title, and class number/subject (###-###) below for each class you are enrolling in.
Submitting this form does not guarantee a seat in the class. Availability is determined when registration and payment (if required), are entered by college staff.

CRN (i.e. 30123)

Class or Exam Title

Subject/Course (i.e. 801-123)

Step 4 - State Data Survey:
Please answer the following questions. This information is requested for state and federal reporting purposes only. When reported, this information is not personally identifiable. Moraine Park Technical College maintains this information in compliance with FERPA and federal privacy requirements. Accurate data enables Moraine Park to obtain state and federal funding that supports education and service to our students.
Your response is appreciated.

1. Highest Grade Completed at enrollment:

2. Highest Credential Received at enrollment:

3. Highest degree earned by either parent:

4. Veteran Status:

5. Work Status at enrollment:

6. Single Parent:
(Are you single, separated, divorced, or widowed and raising children under age 18?)

7. Disability:

8. Foster Care Youth:

(Are you between the ages of 16-24 and are or were part of the foster care system?)

9. Do you meet the criteria for being homeless?:

(In the past year have you been homeless? This could include living in your car, sleeping on a friend's couch, staying in a shelter or living in temporary housing - like a motel).

10. Parent in Armed Forces:
(Are you between the ages of 16-24 with a parent on active duty in the armed forces?)

11. Economically Disadvantaged:

(Includes any individual or member of a family who is unable to pay for one or more basic living needs, who receives need-based financial assistance, or whose income is at or below the poverty level as defined by the U.S. Department of Health and Human Services.)

Step 5 - Payment of Tuition and Fees

Please enter name of your Fire/EMS Department:

I have read and agree to the following:

My tuition is being funded by a third party sponsor (i.e. Employer, Fire/EMS Deparment)
*I have received notification from my employer prompting me to register for the courses they are sponsoring.

*Any charges not covered by the third party vendor are the sole responsibility of the student.
Authorization must be on file in order to process registration and for third party billing to occur.

· I agree to pay any amount not covered by the sponsor in full or to set up a payment plan prior to the payment deadline.

· I understand that MPTC will invoice the third party sponsor one time after the refund period for drop/withdrawals has concluded for the

term.

· I authorize MPTC to release necessary financial information to the sponsor for purposes of invoicing (This may include electronic methods).

· If the third party fails to make payment, it will become my responsibility to pursue the matter and to provide payment to MPTC immediately.

· If my account is left unpaid, a hold will be placed preventing future registration, transcripts, or services and I may be referred to outside

collections and will be responsible for any collection costs.

· My Sponsor has already submitted the Third Party Sponsorship Application.

· I have submitted the Authorization to Release Information.

Step 6 - Agreement / Submit Registration

Submitting this registration form does not guarantee placement into selected classes. Registrations are processed on a first come first served basis. Enrollment is based on class availability and payment (if required) of tuition and fees.

Moraine Park Technical College collects your Social Security Number for record keeping and statistical purposes related to auditing, enforcing, and evaluating federally supported education programs (Federal Law 20 U.S.C.s. 1232g (1998)) only. You are required to provide your Social Security Number for IRS 1098T tax reporting.

By submitting this form, I agree to the Moraine Park Technical College’s Financial Responsibility Agreement and Moraine Park policies as published in the College Catalog. Further, I understand and acknowledge that I am legally and financially responsible for any tuition and fees incurred by such registration in accordance with the Moraine Park Financial Responsibility Agreement. Should I choose not to attend, I will drop the class(es) prior to the day the class(es) begins to avoid any tuition and fee charges. I understand that drops that occur on or after the first day of a class will result in tuition charges to my account.

This form MUST be completed by the student who will be attending the course(s).

Funding Sponsor Name:

Funding Sponsor Phone:

Funding Sponsor Billing Address:

Moraine Park Technical College is an equal opportunity and affirmative action College. Women, minorities, those with different abilities and veterans are encouraged to apply. For more information, visit morainepark.edu/nondiscrimination.

Please wait for files to finish uploading