Terry Wadsley - Carteret Community College Community College 3505 Arendell Street, Morehead City, NC...
Transcript of Terry Wadsley - Carteret Community College Community College 3505 Arendell Street, Morehead City, NC...
Carteret Community College 3505 Arendell Street, Morehead City, NC 28557‐2989
“Education for Life”
Tele: (252) 222‐6000
www.carteret.edu
October 02, 2017
To: EMT Program Applicant
From: Terry Wadsley, AAS, Paramedic
CE EMS Coordinator
Carteret Community College
Reference: CCC EMT Program Interest
Dear Prospective EMT Program Applicant:
Thank you for your interest in applying for admission to Carteret Community College’s, Corporate and Community Education Division’s EMT Program. The purpose of this information is to help you in completing your records for application and to explain the method of selecting students for the program.
The EMT at Carteret Community College (CCC) is accredited by the North Carolina Office of EMS and is approved by the North Carolina Community College System. The CCC EMT Program meets the current standards of the National EMT education standards. In addition, the program is consistent with the National EMS Education Agenda for the Future.
The EMT Program is the foundation of pre-hospital care and introduces the student to the world of pre-hospital medicine. The EMT Program is one semester and is taught in the spring of each year. This course introduces basic emergency medical care. Topics include preparatory, airway, patient assessment, medical emergencies, trauma, infants and children, and operations. Upon completion, students should be able to demonstrate the knowledge and skills necessary to achieve North Carolina State or National Registry EMT certification.
Graduates of this program may be eligible to take state and/or national certification examinations. Employment opportunities include providers of emergency medical services, fire departments, rescue agencies, hospital specialty areas, industry, educational and government agencies.
Terry Wadsley, AAS, Paramedic
Terry Wadsley
CE EMS Coordinator
Carteret Community College
3505 Arendell St.
Morehead City, NC 28557
tel. (252) 222-6029
fax (252) 222-6263
e-mail: [email protected]
Carteret Community College 3505 Arendell Street, Morehead City, NC 28557‐2989
“Education for Life”
Tele: (252) 222‐6000
www.carteret.edu
CCC EMT PROGRAM (Fall 2018)
Explanation of EMT Program Entry Requirements
EMT Program Admission Requirements:
The EMT Program accepts 24 students for continuing education (CCED).
CCED: EMT Program
There is no application fee for the CCED EMT Program. You must meet the admission requirements for the EMT Program. If you
have any further questions contact Terry Wadsley, at 252-222-6029 or by email at [email protected].
You need to bring the following documentation to your orientation session:
Government Issued Photo ID
Copy of high school diploma or GED
You can work with the Academic Support Office at CCC to schedule any placement testing you need to meet
these requirements. The entry requirements mandated by the NC OEMS are as follows:
You must have a high school diploma or GED or place into a 11th grade reading level on the college’s placement test. o You must take and pass the Carteret Community Colleges placement test demonstrating competency in reading. o Entrance Test Scores
Reading placement into ENG 095 or completion of ENG 111 or equivalent.
EMS Program Application Process, Orientation and Registration Session The number of applicants accepted into the program is limited. We will accept students in order of received completed EMS Program
Application packets. The application approval process is printed on the checklist at the end of this letter. This is the same checklist
used to validate packets by the EMS Program Coordinator. You will be notified of you acceptance into the EMS Program during the
orientation session. Once you receive your EMS Program Acceptance letter you will then need to register for EMS classes at the end
of the orientation and registration session. Please bring all monies for all fees with you to the orientation and registration session
on January 08, 2018, Wayne West Room 119B
**Admission to the program is based on meeting all criteria on a first come, first served basis.**
EMT Program Entry Requirements
Each EMT Program accepts 24 students maximum, so the first 24 students to complete all the EMT Program entry requirements will be awarded seats in that section of the EMT Program Cohort class of 2018.
The following completed documentation is due at the orientation and registration session on January 08, 2018:
EMS Program Application.
Background Checks
o Criminal Background checks are required for all EMS Students by our clinical providers. o DO NOT GO TO THE SHERIFFS DEPARTMENT AND GET ONE AS THIS WILL NOT SUFFICE.
US Info Group Criminal Background Check (The US INFO Group version only).(will be done after registration)
Copy of government issued photo ID must be included with your application.
Copy of high school diploma or GED must be included with your application.
Admissions test scores or copies of your official college transcripts must be presented to validate entry requirements.
Payment for the course
o $180.00 Registration Fee (Can be waived with verification of department membership). o $.55 Student Insurance Fee (CAN NOT BE WAIVED). o $4.00 BLS Card Fee (CAN NOT BE WAIVED).
Government Issued Photo ID
A copy of your current driver’s license is required for all students as proof of age and identity. Example of acceptable forms of ID:
NC Driver’s License or NC ID card.
Military ID.
Carteret Community College 3505 Arendell Street, Morehead City, NC 28557‐2989
“Education for Life”
Tele: (252) 222‐6000
www.carteret.edu
EMT Program Timeline and Program Costs Important Dates and Times: MANDATORY ORIENTATION IS January 08, 2018 at 18:00 IN THE WAYNE WEST BUILDING, ROOM 119B.
Start Dates: Jan 22, 2018 thru May 09, 2018, Carteret Community College
Class Times: EMS 4200 EMT Weekly on Monday & Wednesday.& First Saturday of each month. The remaining course work will be
completed on the Moodle section of the class.(Monday/Wednesday 18:00 – 22:00:00, Saturday 08:30 – 17:30)(lunch 12:00 – 13:00)
o Clinical: Students are required to complete a minimum of 24 hours of EMS field observational ride time. More information about clinical will be given during EMT Program Orientation.
Program Costs Pre-Course Fees: The US INFO Group Criminal Background Check is due on April 30, 2018
o Background Check $25.00
Registration Fee: $180.00 unless fee exempt, letter from department required. (Due at Registration)
Student Insurance Fee: $.55. (Due at Registration)
CRP Card Fee: $4.00 (Due at Registration)
Text Books: Emergency Care and Transportation of the Sick and Injured. 11th ed. Package is REQURED) & Basic Life Support for Healthcare Providers: 2016 Guidelines available in book store
Clinical Uniform and Supplies: See Attached CCC Paramedic Program Uniform Order Form. DO NOT PURCHASE ANY UNIFORM/EQUIPMENT UNTIL YOU HAVE ATTENDED THE ORIENTATION SESSION.
Physical and Mental Requirements of an EMS
The field of EMS can be both physically and emotionally stressful. This medical history form is designed to encourage the applicant to reflect on his or her current health status, include a personal immunization record, and have a physical examination by a physician. Applicants can expect to lift 50 pounds frequently with no maximum, do climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, feeling, talking, hearing, and seeing on a frequent basis. All of these activities may need to be performed in any type of environment – indoors or outdoors. In addition to the physical demands of the job, applicants may need to deal with challenging emotional, ethical and/or spiritual issues.
EMT Student Medical Requirements
The nature of EMS may include exposure to blood/body fluids and disease-causing organisms. Immunizations must be current in order to attend clinicals, a required part of the class.
This is a list of immunizations you will be required to present proof of: 1. Complete Tuberculin Screen Form 2. Rubella Vaccine or Titer (3 day measles) 3. Rubeola Vaccine or Titer (5 day measles, hard measles, red
measles) 4. Parotitis Vaccine or Titer (Mumps)
5. Tetanus and Diptheria Adult Vaccine (Td)
(current with past ten (10) years) 6. Hepatitis B Vaccine Series of (3) or Titer required 7. Varicella Vaccine Series of (2) or Titer (Chicken Pox)
required 8. Flu shot is required during flu season (September to
March each year)
EMS Program Entrance Requirement Checklist
Below are the steps for EMS Program Admission.
EMS Program Application Government Issued Photo ID
Copy of Admissions Test Scores Official College Transcripts submitted to Registrar
_____ High School Diploma or GED Attend Orientation Session
Carteret Community College 3505 Arendell Street, Morehead City, NC 28557‐2989
“Education for Life”
Tele: (252) 222‐6000
www.carteret.edu
Background Checks
FACT SHEET ON LEGAL ISSUES
Criminal Background checks are required for all EMS students by our clinical providers. National Criminal Background Checks are completed through a contract provider. DO NOT GO TO THE SHERIFF’S DEPARTMENT AND GET ONE AS THIS WILL NOT SUFFICE.
State Felony Statement:
1. Do you, as the person accepting responsibility by signing this form, have charges pending or have a conviction for a felony or misdemeanor other than a minor traffic violation or a judicial finding of eligibility for treatment in lieu of conviction (even if expunged or sealed)?
2. Have you committed any act in another state that, if committed in North Carolina, would be applicable to caption (1.) listed above?
If you answered “YES” to any of the above questions, please read on:
Actual certification to practice EMS within North Carolina is regulated by the North Carolina Office of EMS and the North Carolina Medical Care Commission. This body needs to evaluate all candidates for certification who answer “YES” to the above questions. The North Carolina Office of EMS will evaluate candidates ONLY upon successful completion of an EMS training program.
National Registry Felony Statement:
1. Do you currently engage in the illegal use of controlled substances, alcohol, or other habit forming drugs or chemical substances?
2. Have you committed fraud or material deception in applying for, or obtaining a certification to practice issued under North Carolina Statutes?
If you answered “YES” to any of the above questions, please read on:
If an individual has answered “YES” to any of the above questions. He/she must submit documentation to the National Registry office that fully describes the offense, copies of relevant court documents, disposition, and current status prior to receiving approval to sit for the National Registry examination. Prospective EMT or Paramedic students can request a review by the National Registry.
In the letter, the prospective student should state that he/she plans to enter an EMS education program and requests permission to sit for the examination upon successful completion of the EMS education program. The decision at this level allows the student to sit for testing only.
EMS PROGRAM APPLICATION
CARTERET COMMUNITY COLLEGE
MOREHEAD CITY, NORTH CAROLINA 28557 Phone (252) 222-6082 PLEASE PRINT OR TYPE
EMERGENCY MEDICAL SERVICES PROGRAM APPLICATION
Application for Acceptance
Please check one EMT-Basic (EMT-B Continuing Education) EMT-Paramedic (EMT-P Continuing Education)
Paramedic Diploma (D45340) , AAS in EMS (A45340, 2 Yr. Degree), AAS in EMS (A45340B Bridging Degree) Disclaimer: Completing this form does not guarantee entry into any EMS program. Specific program requirements must be met prior to acceptance.
PERSONAL INFORMATION
_P NC OEMS P Number
Complete Name (Last) (First) (Middle)
Present Mailing Address Street, Apt., or Box Number
City
State
Zip
County
Date of Birth Month/Day/Year
Home Phone
Cell Phone
E-Mail Address
EDUCATION
Highest Level of Formal Education: GED High School Adult High School College Certificate Associate Degree Bachelor’s Degree
Master Degree or Higher Date of Completion Certificate/Degree _
North Carolina EMS Certification Yes No (If yes, include copy of card)
If Yes, Please List EMT Certification Level Exp. Date
National Registry EMT Yes No (If yes, include copy of card)
If Yes, Please List Certification Level Date
AHA Healthcare Provider I do not have a CPR card
ARC Professional Rescuer
ASHI Professional CPR
CPR Expiration Date
(include copy of card)
Driver’s License Number and State and expiration date
(include copy of driver’s license)
Are You Currently Working in EMS?
Yes No
Agency or Department
Approximate Hours Worked Per Week
CRIMINAL BACKGROUND AND DISABILITIES STATEMENT
HAVE YOU EVER BEEN CONVICTED OF A CRIME? ARE YOU CHARGED WITH OR ON PAROLE/PROBATION FOR ANY CRIME?
YES NO IF YES, PLEASE EXPLAIN AND ATTACH ANY SUPPORTING DOCUMENTS
DO YOU HAVE ANY PHYSICAL OR LEARNING DISABILITIES IN WHICH YOU REQUIRE REASONABLE ACCOMMODATIONS?
YES NO IF YES, PLEASE EXPLAIN AND ATTACH COPY OF THE DISABILITY DETERMINATION, (ACCOMMODATIONS MUST BE APPROVED BY CCC COMPLIANCE OFFICER)
REFER TO THE APPLICATION INFORMATION FOR SPECIFIC DETAILS REGARDING ENTRANCE REQUIREMENTS. PLEASE REMEMBER THAT IT
IS THE STUDENT’S RESPONSIBILITY TO ACCOMPLISH THE ADMISSION REQUIREMENTS.
I certify that I have read and understand the enclosed application information. I also certify that the above information is correct and complete to the best of my knowledge and belief. I understand and agree that misrepresentation, falsification or omission of material fact may be cause for rejection of my application, or for
termination after acceptance into the EMS program.
Applicant Signature X Date of Application
For Office Use Only
EMS Credential _
AHA HCP CPR
HSD/GED Gov. Issue ID
PLACMENT TEST: reading
writing
math
CCC EMS Program 11/13/2014
Carteret Community College “Education for Life”
3505 Arendell Street, Morehead City, NC 28557-2989 Tele: (252) 222-6000
www.carteret.edu
October 02, 2017
To: Carteret County Public Safety Department Chiefs and Training Officers
From: Corporate and Continuing Education Division
Carteret Community College
Reference: Verification of Department Affiliation for Fee Exemption
This form will be used to verify eligibility of approved department personal for fee exemption in
courses sponsored by the Corporate and Continuing Education Division or Carteret Community
College.
Instructions
• To verify a single individuals department fill out section 1.
• To verify an entire departments status of fee exemption attach a current department roster
and fill out section 2.
Section 1
I verify that is a member of
Department in good standing as of / _/ _.
Officer Name:
(Please Print)
_, Officer Signature:
Title: , Phone Number:
(Please Print) (Please Print)
Section 2
I verify that the attached roster is a true list of Departments membership
roster as of / _/ .
Officer Name:
(Please Print)
_, Officer Signature:
Title: , Phone Number:
(Please Print) (Please Print)
Attach a copy of the roster to this form. An Equal Opportunity Educational Institution Serving the Community
without regard to Race, Creed, Sex, National Origin or Disability
Carteret Community College
3505 Arendell Street, Morehead City, NC 28557-2989
Education for Life”
Tele: (252) 222-6000
www.carteret.edu
1
1
2 4 4
4 4
EMT Students please return the following immunization verification to your instructor
along with a copy of you immunization records.
Student Name: ID Number:_ Date:
Part 1: Required vaccinations by age STUDENTS 17 YEARS OF AGE AND YOUNGER
DTP or Td Polio Measles Mumps Rubella
3 3 2 2 1
STUDENTS BORN IN 1957 OR LATER AND 18 YEARS OF AGE OR OLDER
DTP or Td Polio Measles 2,3
Mumps Rubella
3 0 2 2 1
STUDENTS BORN BEFORE 1957
1 4
DTP or Td Polio Measles Mumps Rubella
3 0 0 0 1
STUDENTS 50 YEARS OF AGE AND OLDER
1
DTP or Td Polio Measles Mumps Rubella
3 0 0 0 0
Part 2: Evidence of the following vaccinations according to the Do you currently have any of the following symptoms?
1) Polio vaccine (Student age 17 or and younger 2013) YES NO
2) Rubella vaccine or Titer (3 day measles) YES NO
3) Rubeola Vaccine or Titer (5 day measles, hard measles, red measles) YES NO
4) Parotitis Vaccine or Titer (Mumps) YES NO
5) Tetanus and Diptheria Adult Vaccine (Td) current with past ten (10) years YES NO
6) Flu shot recommended during flu season* YES NO
7) Varicella Vaccine (series of 2) or Titer (Chicken Pox) is recommended* YES NO
8) Hepatitis B Vaccine Series or Titer** YES NO
9) Annual TST (TB) skin test (current within past 90 days or NEG Questionnaire) YES NO
*Recommended immunizations/vaccinations and are just that recommended. You should discuss the risks and benefits of the immunizations/vaccinations with your health care provider. **Hepatitis B (HPV-B) is a highly communicable blood bone pathogen. Health care works are at great risk for exposure to this disease. If you opt not to be
vaccinated for HPV-B you will have to sign a waiver before you can participate in clinical. Please note many EMS agencies will NOT hire an EMT who has not been vaccinated against HPV-B due to the risk of contracting the disease.
Instructor Name Printed:
Instructor Signature: Date:
An Equal Opportunity Educational Institution Serving the Community
without regard to Race, Creed, Sex, National Origin or Disability
Carteret Community College
3505 Arendell Street, Morehead City, NC 28557-2989
“Education for Life”
Tele: (252) 222-6000
www.carteret.edu
Please complete the following TB screening questionnaire and return it
with your physical form to your instructor.
Name: ID Number:
Date:
Part 1: Tuberculosis Risk Questionnaire
1) Were you born outside the USA in one of the following parts of the world: Africa, Asia, Central
America, South America or Eastern Europe YES NO
2) Have you traveled outside the USA and lived more than one month in one of the following parts of the
world: Africa, Asia, Central America, South America or Eastern Europe YES NO
3) Do you have a compromised immune system such as from any of the following conditions:
HIV/AIDS, organ or bone marrow transplantation, diabetes, immunosuppressive medicines (e.g.
prednisone, Remicade), leukemia, lymphoma, cancer of the head or neck, gastrectomy or jejeunal
bypass, end-stage renal disease (on dialysis), or silicosis?
YES NO
4) Have you ever done one of the following: used crack cocaine, injected illegal drugs, worked or
resided in jail or prison, worked or resided at a homeless shelter, or worked as a healthcare worker
in direct contact with patients?
YES NO
5) Have you ever been exposed to anyone with infectious tuberculosis? YES NO
Part 2: Tuberculosis Symptom Questionnaire
Do you currently have any of the following symptoms?
1) Unexplained cough lasting more than 3 weeks. YES NO
2)
Unexplained fever lasting more than 3 weeks
YES
NO
3)
Night sweats (sweating that leaves the bed clothes and sheets wet)
YES
NO
4)
Shortness of breath
YES
NO
5)
Chest pain
YES
NO
6)
Unintentional weight loss
YES
NO
7)
Unexplained fatigue (very tired for no reason)
YES
NO
An Equal Opportunity Educational Institution Serving the Community without regard
to Race, Creed, Sex, National Origin or Disability
Emergency Medical Science Program
Effective 2017
I. EMS Program Re-Admission Procedure
A. If a student does not successfully complete the first semester of the Program, the student
MUST re-apply to the Program for the next academic year.
B. Student Conduct Violation
i. A student that is dismissed from the College due to a violation of the College’s
Student Conduct Policy is not eligible for re-admission to the Program.
ii. A student that is dismissed from the Program due to a violation of the NC EMS
Practice Act may not be eligible for re-admission to the Program.
1. The student must be cleared of all allegations made by the NC OEMS Disciplinary
Board in order to be eligible for re-admission.
C. Re-admission is not guaranteed due to the competitive admission process. D. Refer to
the published admission requirements for fall 2014.
II. Program Re-Entry Procedure
A. Definitions of Withdrawal
i. Involuntary Withdrawal
1. Academic
a. A student that does not achieve a grade of “C” or better for courses in the
curriculum plan with an EMS, MED, or BIO prefix.
2. Physical / Mental Health Issues
a. A student that is withdrawn from the Program due to the inability to
meet program requirements.
3. Student Conduct Violation
a. A student that is dismissed from the College due to a violation of the
college’s Student Conduct Policy is not eligible for re- admission to the
Program.
b. A student that is dismissed from the Program due to a violation of the NC
EMS Practice Act may not be eligible for re- admission to the Program.
i. The student must be cleared of all allegations made by the NC
OEMS Disciplinary Board in order to be eligible for re-entry.
ii. Voluntary Withdrawal
1. Physical / Mental Health
a. A student that withdraws from the Program due to physical or mental
health issues.
2. Personal
a. A student that withdraws from the Program due to personal reasons (e.g.
financial, child-care issues).
B. Involuntary Withdrawal
i. Academic
1. If a student wishes to be considered for re-entry the next academic year, the student
must:
a. Submit an updated EMS Program Application to the Program
Curriculum Area Coordinator (CAC).
b. Schedule a meeting with the EMS CAC to discuss any re-entry criteria that was
listed in the academic dismissal letter, if one was issued.
c. Submit a current Student Medical Form.
d. Repeat the criminal background check and drug screen. e. Present
proof of current AHA BLS certification.
2. Re-entry in the program is not guaranteed.
a. Re-entry is only possible if there is a space available in the next year’s class.
b. Students will be notified of their re-entry status at least 30 days prior to the date
of requested re-entry.
3. A student may only re-enter through this procedure once. If the student is unsuccessful
at this attempt, counseling will be provided to explore other career opportunities.
ii. Physical / Mental Health
1. If a student wishes to be considered for re-entry the next academic year, the student
must:
a. Submit an updated EMS Program Application to the Program
Curriculum Area Coordinator (CAC).
b. Schedule a meeting with the EMS CAC to discuss the criteria for re-entry.
c. Submit a current Student Medical Form.
d. Repeat the criminal background check and drug screen. e. Present
proof of current AHA BLS certification.
f. Provide documentation from a licensed healthcare provider stating that the
health issue is now resolved or is currently being managed successfully.
i. This documentation is in addition to the Student Medical Form that
is required of all students in the program.
2. Re-entry in the program is not guaranteed.
a. Re-entry is only possible if there is a space available in the next year’s class.
b. Students will be notified of their re-entry status at least 30 days prior to the date
of requested re-entry.
3. A student may only re-enter through this procedure once. If the student is unsuccessful
at this attempt, counseling will be provided to explore other career opportunities.
iii. Student Conduct Violation
1. A student that is dismissed from the College due to a violation of the college’s Student
Conduct Policy is not eligible for re-admission to the Program.
2. A student that is dismissed from the Program due to a violation of the NC EMS
Practice Act may not be eligible for re-admission to the Program.
a. The student must be cleared of all allegations made by the NC OEMS
Disciplinary Board in order to be eligible for re-entry.
C. Voluntary Withdrawal
i. If a student withdraws from the program voluntarily, the student may be considered for re-
entry the next academic year by fulfilling the following requirements:
1. Submit an updated EMS Program Application to the Program
Curriculum Area Coordinator (CAC).
2. Schedule a meeting with the EMS CAC to discuss the criteria for re- entry.
3. Submit a current Student Medical Form.
4. Repeat the criminal background check and drug screen.
5. Present proof of current AHA BLS certification.
6. A student who withdraws from the program for physical or mental health reasons
will be required to provide documentation from a licensed healthcare provider
stating that the health issue is now resolved or is currently being managed
successfully.
a. This documentation is in addition to the Student Medical Form
that is required of all students in the program.
ii. Re-entry in the program is not guaranteed.
1. Re-entry is only possible if there is a space available in the next year’s class.
2. Students will be notified of their re-entry status at least 30 days prior to the date of
requested re-entry.
iii. A student may only re-enter through this procedure once. If the student is unsuccessful at
this attempt, counseling will be provided to explore other career opportunities.
D. Re-Entry Timeline
i. If a student does not re-enter the next academic year, the student must apply for re-admission.
1. Re-admission is not guaranteed due to the competitive admission process.
2. Refer to the published admission requirements for the applicable academic year.
Carteret Community College “Education for Life” 3505 Arendell Street, Morehead City, NC 28557-2989 Tele: (252) 222-6000
EMS Program Readmission Policy
Readmission to the EMS Program
Student who are unable to complete the EMS Program with their assigned cohort and wish to
reapply for admission into a new cohort must meet the following guidelines.
• Complete an update Carteret Community College application as per admissions policy.
• Complete an updated EMS Program Application and submit it the EMS Program CAC.
• Schedule a meeting with the EMS CAC to discuss any readmission criteria that was listed in the academic dismissal letter if one was issued.
o Students who are removed for violation of the academic integrity are not eligible for readmission to the EMS Program.
o Students who violate the NC EMS Practice Act must be cleared of all allegations by the NC OEMS Disciplinary Board prior to reinstatement.
I have received a copy of the Carteret Community College EMS Program Readmission Policy. I have read and understand this policy.
Student Name Print Student Signature Date
Instructor Name Print Instructor Signature Date Sales Tax
Grand Total
CARTERET EMS PROGRAM
Student Online Criminal Background Check/Drug Screen Request Procedure
The cost for your Criminal Background Check is a flat fee of $25. Required for all EMS Students
The cost for a 12 Panel Drug Screen is $47. Required for EMT-P Students ONLY
a. Go to: www.usinfogroup.com
b. Click on the University/Community Colleges Student Access picture box.
c. Enter the following USERID and Password.
School User ID: CCCEMS
School Password: student
d. Click on “Secured Login”
e. Follow the instructions to request your criminal background and/or Drug Screen:
Please note you must have an active email address to complete the ordering
process. f. If you are ordering a drug screen you will receive an email with a drug screen
registration form attachment. Print the form and go to the drug testing facility
location listed on the form.
Drug screens must be completed no later than 48 hours from the date the
on-line registration is created. The expiration date and time is notated at the
top of the form. g. Your Criminal Background Check/Drug Screen will be processed upon
successful processing of your credit/debit card.
h. Upon completion of your Criminal Background Check/Drug Screen, you will
receive an email from USInfoGroup notifying you of the completed request(s).
i. To view your completed request(s), follow the steps above for a, b, c and d.
Follow the instructions for returning students.
j. Upon completion of your request, an electronic copy will be forwarded to your
clinical site(s) if they are known.
If you do not have access to a computer please call (919) 570-9861 and one of our customer
service representatives will be available to assist you.
Revised 11/13/2014
CARTERET COMMUNITY COLLEGE
STUDENT REGISTRATION FORM Corporate & Community Education Contract # _________________
COURSE INFORMATION
1. 11.
Instructor
STUDENT INFORMATION
2. SSN: - - 12. Sex: (check one) 1-Male 2-Female
3. Name: 13. Race: (check one) 1-White 2-Black
3-Indian 4-Hispanic 5-Asian
4. Mailing Address: 14. Highest Grade Completed: or:(check one)
(--)GED Diploma (15)Associate Degree
5. City: (13)Adult High School (16)Bachelor's Degree
(14) 1 Year Voc Diploma (17)Masters Degree or higher
6. State: Zip:
7. Phone Number: Home: 15. Residence: State County Name
Work: 16. Vocation:
8. Birthdate: 17. Employment:(check one) (F)Full-time (1)Retired
(P) Part-time All students under 18 must complete a dual enrollment form to attend class.
(U) Unemployed
18. Employer:
9. Email Address: @
10. Student's Signature 19. Date
THIRD PARTY BILLING STATEMENT If prior authorization has not been received/given to CCC for the student's fees to be paid by a third party you must sign the following statement:
I agree to pay all charges associated with this class if my company refuses payment.
Signature
Company Name Who to Contact about payment Phone#
CARTERET COMMUNITY COLLEGE
Corporate & Community Education COURSE RECEIPT
Payment:
Check
Cash
$ Registration Fee $ Insurance Fee $ Book Fee $ Supply Fee $ Donation to Dept $ Misc. Fee $ Total Received
Student Name:
Course Name Contract #
Received by: Date:
(Instructor's Signature- Only sign if money is received from this student)