EMS & Fire Personal Pay Request

Time remaining in this session. When it reaches 0, unsaved work will be lost.

--:--

* = required field

Some content may be updated based on selection

EMS & Fire Personal Pay Request Form
(No Department or Service Affiliation)

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

Date:

If you interested in taking a continuing education FIRE or EMS course but you are NOT affiliated with a department or service, please complete this request form.

Last Name

First Name:

Middle Initial

Former Name/s (if applicable):

Student ID # (if known):

Gender:

Date of Birth:

City:

State:

Zip Code:

Primary Phone:

Phone Type:

Personal Email Address:

Enter the course title for the classe(s) interesting in taking.

Course Title

Comments/Questions

Once you have submitted this form, you can expect an email response from MPTC Enrollment Services regarding the status of your request and next steps within 24 business hours.

Enrollment Services Hours: Monday-Friday from 8:00am to 4:30pm (closed on holidays and on Fridays in June & July)

Signature

Please wait for files to finish uploading