Center for Workforce & Community Development
REGISTRATION FORM
Male
Yes
No
Advanced Course
Career/workforce training
Healthcare
Professional Development workshops
Small Business Development Center
Personal Enrichment
Linked class
Kids at College Summer camp Information Sessions
I grant Lee College permission to use/release any of the provided information, photographs, comments or directory information. I understand I
will not be paid for any use of my images, videos, or comments now or in the future.
Date:
TERM: __
__________
Registration Information
Last Name First Name Middle Initial Student ID (if known)
Home Address City State ZIP
Country Primary Phone Alternative Phone Sex
Female
Email Address
Date of Birth Social Security Number
Emergency Contact Relationship Phone Number
Demographic and Residency Information
This information is r equired and will be used in a nondiscriminatory manner, consistent with applicable civil rights l aws. This information will be used for federal
and/or state law reporting purposes only.
Check all that apply
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
International Only
Multi-Racial
Native Hawaiian/Pacific Islander
Not Hispanic/Latino
White
Other
Additional Information (check all that apply)
Displaced Homemaker (Homemaker now in need of employment or
employment upgrade due to loss of support from spouse)
Academically Disadvantaged (Less than HS Diploma)
Economically Disadvantaged (Household income less than $15,000
per year)
Single Parent
Disabled (legally blind, deaf, speech impaired, wheelchair bound,
learning disabilities, etc.)
Limited English Proficiency
Have you been a resident of TX
for 12 months or more?
If no,
State:
Country:
Course Information
Payment Information
Choose One: Cash Check Visa MC Discover AMEX
Card Number Cardholder Name CVV Code Exp. Date
Billing Address: Check if same as above
TX DL# TDL Exp. Date Check numbe
Enrollment Information
If this your first c ourse at t he Center for Workforce and Community
Development?
Yes
No
How did you hear about this course?
Email
News article
Employer Website
Social Media
Referral Walk-in Workforce Solutions Event Other:
Check the boxes next to your interest areas:
Computer Technology
Recreation and Fitness
Senior Adult & Travel
Adult Ed/Literacy
Online Education
Release Agreements and Student Signature
Student Signature:
For Office Use Only
Receipt Number Date Staff Initials Notes
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signature
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