EMS & Fire Sponsored Member Registration Form (MPTC)

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EMS & Fire Sponsored Member Registration and
Authorization for Release of Student Records Form

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

Date:

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

Your registration is not considered complete until you have received a confirmation email and course schedule from Enrollment Services.
Enrollment Services processes registration requests manually within 3 business days on a first come first served basis. Same day form processing cannot be guaranteed.
Course registration is based on class availability and payment (if required) of tuition and fees.
View CLASS OFFERINGS to verify there are seats available in the course(s) you are requesting prior to submitting a registration form.

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

Step 1 - Demographic & Address Information

Last Name

First Name:

Middle Initial

Former Name/s (if applicable):

Student ID # (if known):

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?

Gender:

Date of Birth:

Social Security Number:

U.S. Citizen?

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

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

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

Personal Email Address:

Do you have a Fire Certification Number?

Are you a high school graduate?

High School Grad Date:

High School Attended:

City/State:

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

Date of HSED/GED Completion:

Step 2 - 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 3 - Registration for Classes
Please enter the five-digit number (CRN) and title below for each course or exam you would like to enroll in.

If you do not know the CRN refer to the schedule that was emailed to your department.
Or call Enrollment Services at 1-800-472-4554 and ask for Jill or Bryce.

CRN (i.e. 40123)

Class or Exam Title

Step 4 - Sponsoring Department Information

If any of the information in this section is incomplete, you will be required to complete a separate Student

Authorization for Release of Education Information form before your registration will be processed.

What Fire/EMS Department is sponsoring you:

City:

State:

Zip Code:

First and Last Name of Your Sponsoring Department's Contact PERSON:

Phone Number for Your Sponsoring Department's Contact Person:

Email Address for Your Sponsoring Department's Contact Person:

NOTE - Do not enter your own Email Address here

A copy of your registration information and schedule will be emailed to your department contact.

Step 5 - Agreements & Authorization for Release of Student Records / Submit Registration Form

I have read and agree to the following authorization for release and payment information:

My tuition is being funded by a third party sponsor: I have received notification from my employer prompting me to register for the courses they are sponsoring.

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

By submitting this form:

I certify that the above information is correct. I authorize Moraine Park Technical College to release confirmation of my registration and any academic records related to this training to my employer or personnel/training officer sponsoring the training.

I agree to the Moraine Park Technical College’s Financial Responsibility Agreement and Moraine Park policies as published in the current 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.

I certify that I have read and agree to the following release of liability:

I understand and appreciate the risks that are inherent in fire training ("activity") and that certain risks cannot be eliminated regardless of the care taken to avoid injuries. I am aware of the risks of participation in the activity, which include, but are not limited to, the possibility of physical injury, fatigue, bruises, contusions, broken bones, concussion, paralysis, exposure to bodily fluids, bloodborne pathogens, communicable disease, needle sticks and sharp injuries, damage/destruction to property, and even death. I understand that it is my responsibility to ensure I am physically capable of participating in this activity. I understand that if medical treatment is necessary, that the costs associated with preliminary tests, vaccinations, diagnostic tests, and treatment associated with illness(es), injury(ies), and blood and/or body fluids exposure is my responsibility. In consideration of my participation in this activity, I, for myself, spouse, partner, heirs, personal representatives, estate or assigns, hereby waive, release, and discharge the COLLEGE, including its Board of Trustees/Directors, administrators, officers, employees, teachers, agents and insurers, from any and all claims, causes of action, suits, damages, or liabilities sounding in negligence, which I have, shall have, or may have in the future against the COLLEGE arising out of, based on, related to, or connected with, my enrollment and participation in the activity. This release of liability does not, however, apply to any intentional or reckless acts or conduct by the COLLEGE.

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

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.

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.

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