Gaston College EMS Education Agency Affiliation Form

Please complete the form below:

Today's Date
MM slash DD slash YYYY
Name * Required
First Last
Student ID Number: (0 to 9 max numbers) * Required
Course Title: Please enter specific title in WebAdvisor * Required
If you are a new student and this is your first time taking a continuing education course through EMS Education, you must contact the EMS Department at gcems@gaston.edu or 704-922-6241 to register.
Fee Exemption Waiver: The responses below will help us determine if you are eligible for fee waiver.
Department of Affiliation: Please completely spell out name (no abbreviations) * Required
Job Classification: (Select One) * Required
- FireFighter (Volunteer)
- Firefighter (Municipal/County/State Agency)
- EMS Responder (Volunteer Agency)
- EMS Responder (Municipal/County/State Agency)
- Emergency Management
- Telecommunications/Dispatcher
- Law Enforcement (Sworn Officer)
Student E-mail * Required
Confirmation of Affiliation * Required
- By clicking this box I attest that I have an active affiliation with the public safety agency listed above and that I hold the job classification as indicated.

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