Fillable CONTINUING EDUCATION REGISTRATION FORM Adult High School Diploma (South Piedmont Community College)

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CONTINUING EDUCATION REGISTRATION FORM Adult High School Diploma (South Piedmont Community College)

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Country of origin: US
File type: PDF

U.S.A. forms for South Piedmont Community College

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If course is Emergency Service: Name of Police, Fire or Rescue Dept. _______________________________________ Paid Volunteer
(circle one)
Have you enrolled in this class more than once? □ Yes □ No How did you hear about the course?
(please specify)
____________________________________________________________________________________________________________________
STUDENT SIGNATURE (required) Date
COURSE INFORMATION
Course No. ________________ Section No. __________________ Title _______________________________________________
Instructor ____________________________________________ Location _____________________ Contact Hours ___________
Beginning Date ________________ Ending Date ________________ M T W Th F Sa Su Time ________________________
SOUTH PIEDMONT COMMUNITY COLLEGE COURSE RECEIPT
$ _________________ Registration Fee
$ ________________ Books $ _____________ Other $ _______________ See Attachment
$ ________________ Total Charges billed to Sponsoring Agency _________________________ Contract Training _____________
$ ________________ Total Charges to Student
Amount Paid $ ___________________ by: □ Student □ Other: _____________________________________________________
Cash __________ Check # ___________ Credit Card: □ VISA □ MC □ AMEX □ Discover Approval Code ___________
Comments: ________________________________________________________________________________________________________________
If student is exempt from registration fee, state reason: □ Vol. Fire □ Paid Fire □ Vol. Rescue □ Paid Rescue □ Law □ Employee
□ Inmate □ Senior (65+) □ HRD □ Correctional Ocer □ Other _________________
Received by: ________________________________________________________________________________________________________________
College Ocial’s Signature Date
L.L. POLK CAMPUS • PO Box 126 • Polkton, NC 28135 • 704.272.5300 | LOCKHART-TAYLOR CENTER • 514 N. Washington St. • Wadesboro, NC 281705 • 704.272.5300
OLD CHARLOTTE HIGHWAY CAMPUS • 4209 Old Charlotte Hwy. • Monroe, NC 28110 • 704.290.5100
| www.spcc.edu
Rev. 05.26.10
CONTINUING EDUCATION REGISTRATION FORM
Social Security Number or SPCC Student ID:
___________________________________________________
Last Name ________________________________________________
First Name __________________________________ MI ________
Address __________________________________________________
City _____________________________________________________
State ______________________________ Zip _________________
County of Residence ________________________________________
Phone H ______________________ W _____________________
Cell _______________________________________________
Date of Birth ______________________________________________
Are you Hispanic or Latino? □ Yes □ No
If no, select one or more races: □ American Indian or Native Alaskan
□ Asian □ Black or African American
□ Native Hawaiian or other Pacic Islander □ White
Employment Status
□ Full-time □ Part-time ( _____ hours per week)
□ Retired □ Unemployed-Not Seeking □ Unemployed-Seeking
Highest Education Level
□ Non-Graduate (Highest grade completed __________ )
□ GED
□ High School Graduate
□ Adult High School Diploma
□ One-Year Vocational Diploma
□ Associate Degree
□ Bachelor’s Degree
□ Master’s Degree or Higher
E-mail ___________________________________________________
Sex □ Female □ Male
□ Newspaper □ Flyer □ Schedule
□ On-line □ Other ____________
3354A
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CONTINUING EDUCATION REGISTRATION FORM Adult High School Diploma (South Piedmont Community College)

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Completed 26 July 2020

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