Hospitality Heroes Registration Form
Please Print Legibly
Course Title: Hospitality Heroes Month/Year of Class: _________________
Your Name: _____________________________________________________________
County of Residence: ______________________ Handicapped/Disabled: Yes No
Address: ______________________________________________________________________
City: ____________________________________ State: _________ Zip: _______________
Home Phone: ____________________ Cell Phone: ____________________
Date of Birth: _____/_____/_____ Sex: Female Male
Race: White Black Indian Hispanic Asian Other
Highest Grade Completed (circle one):
0 Never Attended 5 Fifth Grade 10 Tenth Grade 14 One Year Vocational Diploma
1 First Grade 6 Sixth Grade 11 Eleventh Grade 15 Associates Degree
2 Second Grade 7 Seventh Grade 12 Twelfth Grade 16 Bachelor’s Degree
3 Third Grade 8 Eighth Grade GED 17 Master’s Degree or Higher
4 Fourth Grade 9 Ninth Grade 13 Adult High School
Employment Status: PT FT Retired Unemployed-Not Seeking
Unemployed-Seeking
Place of Employment: _________________________________ County of Business: ___________________
Work Address: _______________________________________ Business Phone: ______________________
City: ______________________________ State:_________ Zip:______________
Email Address: ___________________________________________________________
Signature: __________________________________________ Date: ___________________
Mail this registration form to Rosa Andrews, JC Workforce Development Center,
135 Bestwood Drive, Clayton, NC 27520 or fax it to 919-359-1176.
