First Name * Middle Name * Last Name * Primary Phone * Alt Phone * Last 4 digits of Social Security * GC ID# * Email * The following information is used for federal and/or state reporting purposes and to help provide support for our programs. Your answers are completely voluntary and will be kept strictly confidential. Please make one selection from each section Ethnicity: * -Select One- Hispanic Non-Hispanic/Latino Decline to Answer Race: * -Select One- Asian Black/African American Hawaiian/Pacific Islander Native American/Alaskan White/Caucasian What is your License # * Agency issuing: * ACLS - Advanced Cardiac Life Support PHTLS - Pre-Hospital Trauma Life Support GEMS - Geriatric Education for EMS TECC - Tactical Emergency Casualty Care PALS - Pediatric Advanced Life Support AMLS - Advanced Medical Life Support First Responders CPR/First Aid Healthcare Providers-CPR (AHA BLS) PAYMENT INFORMATION -Select One- Cash Check Agency Employer Grant Mastercard Visa AMEX Discover Card Number Expiration V-Code The information I have provided is complete and correct to the best of my knowledge. I agree to abide by the policies, rules and regulations in the programs to which I am admitted. I authorize the college to verify the information I have provided. I further understand that the information submitted herein will be relied upon. I understand that by registering for the courses listed above that I am responsible for the payment of the courses listed.
Refunds will only be given if you notify the CE office prior to the course starting date. No Refunds will be given after the course has started and a hold will be placed on your account for any balances owed.Galveston College has established policies and procedures to comply with the “Family Educational Rights and Privacy Act of 1974” and the “Texas Open Records Law” FERPA (State Senate Bill 1071 and House Bill 6). This information is available via our catalog and website. FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR § 99.31): School officials with legitimate educational interest (Galveston College considers personnel instructing/supervising students at clinical, internship, and other practicum sites as school officials); Other schools to which a student is transferring; Specified officials for audit or evaluation purposes; Appropriate parties in connection with financial aid to a student; Organizations conducting studies on certain students for or on behalf of the school; Accrediting organizations; To comply with a judicial order or lawfully issued subpoena; Appropriate officials in cases of health and safety emergencies; and,Federal,State and local authorities, within a juvenile justice system, pursuant to specific state law. You have my permission to use photos in which I appear for GC publicity * Date / Time
It is the policy of Galveston College to provide equal opportunities without regard to age, race, color, religion, national origin, sex, disability, genetic information, or veteran statusUpdated 08/2019