Mail, fax, or deliver completed form and appropriate registration fee to:
Johnston Community College
Attention: Continuing Education
Telephone # (919) 934-3051 Post Office Box 2350, Smithfield, NC 27577 Fax # (919) 209-2189
Complete the registration form in full and return to the address listed above. Please print in ink or type.
/Registration Fee $_____/ Course Code:Course Title_______ __ ___________________________________ ___________________ __
/End DateBegin Date/LocationSemester ______________ ___________________________ ___ ______________ _______________
Colleague ID Date of Birth RaceSex ( ) M ( ) FLast five of SS # __ __ __ __ __ _____________ ___________ ____________
Last First Middle
Address (Street, PO Box) _________________________________________________________________________________________
County of Residence __(City, State, Zip) _______________________________________________________ ______________
Email Address _________________________________________________________________________________________________
(Cell)(Business) Telephone Number (Home) ________________________ ______________________ _______________________
Master’s Degree ___OR Highest Grade Completed Associate Degree ___ Bachelor’s Degree
One Year Vocational Diploma
Adult High School Diploma ___ GED Diploma Completed High School
Education Level: ___ ___
Part-time - Number of hours per week ____ Retired __ Full-time Employment Status: __ __
Unemployed (seeking) Unemployed (not seeking) __ __
Occupation ___Employer: _____________________________________________ _____________________________________
If affiliated, NAME OF AGENCY YOU ARE WITH: (no abbreviations)_______________________________________________
Check AFFILIATIONS that apply:
__ Paid Firefighter __ Corrections/Probation Officer __ Telecommunicator – Law Enforcement
Paid Law Enforcement __ Paid Rescue/EMS __
Other:___ Volunteer Firefighter __ Telecommunicator – Fire __ ___________________________________
__ Volunteer Rescue/EMS __ Telecommunicator - EMS
Johnston Community College does not discriminate in admissions, employment, or in its administration of educational programs and activities on the
basis of age, race, color, sex, national origin, disability, religion, creed, military or veteran status, genetic information, or any other characteristic
protected under applicable federal or state law. Inquiries should be addressed to the vice president of student services or vice president of administrative
services. Inquiries concerning the application of Title IX may be referred to the Title IX Coordinator. JCC’s Title IX Coordinator is Harlan E. Frye,
whose office is in the Wilson Building, room 1023C. This office can be contacted by phone at (919) 209-2025 or by email at email@example.com.
PLEASE READ THE FOLLOWING POLICIES CONCERNING YOUR REGISTRATION.
Continuing Education (CE): A student who officially withdraws (in writing) from a CE course prior to the first class meeting is eligible for a
100% refund of the registration fee (this does not include any others fees) upon request to the CE Division. A student may be eligible to receive
a 75% refund of the registration fee if the student officially withdraws (in writing) from the course after the class begins but prior to the 10%
census date. A student would not be entitled to receive a refund if he/she withdraws after the 10% census date of the course.
Courses offered as self-supporting, (course codes beginning with SEF and CSP) are not eligible for a refund as these programs are
funded by registration fees collected. Students are eligible for a 100% refund if the class is canceled by the College. A student may transfer
ONLY ONCE (within the same semester) to another class if he/she notifies the office a minimum of one week in advance.
The above information is accurate to the best of my knowledge and I have read the Continuing Education Refund Policy and understand how it
applies to my registration for this course.
Date Student Signature _____________________________________________ _______________________
or Money Order Enclosed (Payable to JCC) ( ) Check # Method of Payment: ( ) Cash ___________ _____________
( ) Credit Card- If paying by credit card, please provide a contact number on registration
form to receive a phone call to process your payment.
( ) Sponsorship ___________________________
*Out-of-state checks and Woodforest National Bank checks are not accepted*
*No class confirmation will be mailed* Rev. 3/2020
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