EMS & Fire Self Pay Registration Form (MPTC)

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EMS & Fire Self Pay Registration 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

Select the box(es) corresponding to the course title(s) or exam you wish to enroll in, and enter the five-digit Course Registration Number (CRN) for each.

NOTE: Some courses are not offered every semester, please view class offerings to see the schedule and availability.

Class Title

CRN (i.e. 40123)

Fire/Emergency Services Instructor (503-790)

Emergency Medical First Responder (531-413)

Emergency Medical First Responder Refresher (531-415)

Practical Exam (998-018)

Step 4 - Payment of Tuition and Fees

AFTER receiving a confirmation of registration email from Enrollment Services, I will use MPTC's Guest Checkout to complete the payment process.

The confirmation email will include your course schedule, total amount due and a link to our Guest Checkout.

Step 5 - Agreements / Submit Registration

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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