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Emergency Services / Law Enforcement
Online Demographics Registration Form

* Required information

Information in this area is for record keeping purposes only and will not be used in a discriminatory manner.  However, this information is required for federal reports, state reports and state certification.  This form will be destroyed once it is determined that it is no longer necessary for class registration. Students not including their social security number will not be reported for certification classes to appropriate agencies.

The following information is required by the N.C. Community College System

Today's Date:

*Last Name:    Suffix:
*First Name:  
Middle Name:  
*Social Security Number   (Type numbers only; No spaces or hyphens)
*Email Address:  
Confirm Email Address:  
*Gender:  Female  Male
*Ethnic Origin: (Select one)

 Hispanic (HIS)  (This option will prompt for race)

Datatel ID (If Known):  
*Home Mailing Address:  
*State:    (If State is not NC, please type in correct 2 digit State code)
*Zip Code:   
*County of Residence:  
*Home Phone #:
(Ex.: 8281235555)
  (Include area code; No spaces, hypens, or other special characters)
Cell Phone #:   (Include area code; No spaces, hypens, or other special characters)    
*Date Of Birth:
Employment Status:  
Highest Level of Education Completed:  
If did not complete High School, select the highest grade completed:  
*Date Last Attended High School:

Vocation:(check all that apply) Emergency Medical Fire Department Law Enforcement Rescue Squad

 Department Affiliation:   

Certification of Accuracy

 Yes   No

By choosing "Yes", I certify to the best of my knowledge that the information given is true and complete. Further, I understand that by submitting this information via electronic transmission that I acknowledge the following:

  • I do not have any outstanding balances with Western Piedmont Community College

  • I understand that I cannot register into a class that meets at the same time of another WPCC class for which I am registered.

  • I understand that if I falsify any information on the previous demographics form, or on any future registration forms, my certification will be eliminated.

  • I understand and agree that my electronic signature is the legal equivalent of my manual signature.

  • Permission is granted to release appropriate course information to certifying agencies.

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