Fillable Complete all information and print clearly. Student data (Craven Community College)

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Complete all information and print clearly. Student data (Craven Community College)

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Workforce Development
Registration Form
800 College Court
New Bern, NC 28562
305 Cunningham Blvd.
Havelock, NC 28532
252-638-7248
www.cravencc.edu/wfd
Complete all information and print clearly. Student data on this form is CONFIDENTIAL.
Course:
Course Title
Start Date
Social Security Number:
Colleague ID:
Name:
Last First
Middle
Address:
Street/P.O. Box
City
State
Zip Code
County of Residence:
Date of Birth:
Age:
MM/DD/YYYY
Minors need release
Phone:
E-mail Address:
Please check:
Sex:
Female Male
Ethnicity:
Hispanic/Latino Non-Hispanic/Latino
Race:
American/Alaska Native Asian Black or African American Hawaiian or Pacific Islander White
Employment Status:
Full time Part-time Retired Unemployed-Not Seeking Unemployed-Seeking
Military/Veteran Status:
Active Veteran/Retired Reserve Branch: Army Air Force Marines Navy Coast Guard
Highest Education Level:
Completed Grade: 1 2 3 4 5 6 7 8 9 10 11 12/(HS Graduate)
GED Adult HS Diploma 1-yr Vocational Diploma Associate Bachelor’s Master’s or Higher
Public Safety Fee Waiver Confirmation
Required for Fire/EMS/DPS/Law Enforcement
My signature attests that I am actively affiliated with the public
safety agency listed and that I hold the job classification indicated.
Agency/Dept.:
Job:
LE Officer Detention Officer
Firefighter-Volunteer Agency
Firefighter-County/State/Municipal Agency
EMS Responder-Volunteer Agency
EMS Responder-County/State/Municipal Agency
Emergency Management Personnel
On NC Military Installation: Fire EMS EOP
Other - provide specific job classification:
__________________________________________
Authorization to Release Information
Required for Fire/EMS/DPS/LE; may apply to others
My signature below authorizes the College to release information
regarding my enrollment to (check all that apply):
affiliated agency/department listed above
oversight agency (e.g., OSFM, DPS, OSHA, NCCER)
my employer: _______________________________
Registration Fee Refunds
If a class is canceled due to insufficient enrollment, a student
automatically receives a 100% refund.
A student who officially withdraws from an occupational
extension class prior to the first class meeting is eligible for a
100% refund.
A student who officially withdraws from an occupational
extension class after the start date and prior to or on the 10%
point is eligible for a 75% refund.
Additional provisions of the refund policy, including those
regarding self-support classes and student fees are available
upon request.
For Office Use
201 ce
RGN by (initials)
Date
Year & Term
Registration Fee or Flat rate
$_____________
Other Fee Type: ___________
$_____________
Other Fee Type: ___________
$_____________
Total
$_____________
Waiver/Bill to:
Student Signature:
Date:
An Equal Opportunity Educational Institution ver 2016-08-29
Home:
Cell:
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Completed 26 July 2020

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