Continuing Education/ HRD Registration & Fee Waiver Form
Last Name: _______________________________ First Name: ___________________________ MI: ________
Addr
ess:
__________________________________ City: ____________________ State: ______
Zip: _
______________
County:
_______________________ Home: ( ) ______________
_________
Cell: ( ) ___________________
Colleague
ID
#:
________________________
Email
addr
ess: _______________________________________
Last 4 Digits of Social Security Number: ___________________ Date of Birth: __________________________
Highest Education Level Completed Race Gender
Non-graduate (highest grade completed) _____
White
Female
Male
GED
Black/African American
Employment Status
High School Diploma
American Indian
Full-time
Associate’s Degree
Hispanic/Latino
Part-Time
Bachelor’s Degree
Asian/Pacific Islander
Retired
Master’s Degree or Higher
Unemployed (not seeking)
Unemployed (seeking)
Tuition and Fee Waiver - Verification Statement
The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in classes coded in the Master
Course List as Human Resources Development if the individual meets one of four criteria listed below. To receive this waiver, an
individual must verify that he or she meets at least one of the criteria by completing and signing this form. Individuals not signing this
form must pay applicable fee to register for a Continuing Education Course.
I qualify for a tuition and fee waiver under the following criteria:
1. I am currently unemployed.
3.
I am working and eligible for Federal Earned Income Tax Credit.
Please indicate the number of dependents living in your household: _______
2. I have received notification of pending layoff.
4
. I am working and earn wages at or below 200% of the federal poverty
guidelines.
Have you worked in the past 12 months? If so complete the following:
Employer and Job Title
Start/End Date
Weeks Employed
Hourly Wage
Hours Per Week
Comments
1.
2.
I hereby verify all information I have completed on this form is complete and accurate to the best of my knowledge.
Student Signature:
___________________________________________________________
Date:
_________________________
OFFICE USE ONLY
Amount of Fee Paid Date Paid Institutional Representative
Location of Instruction (Building, Room)
Name of Course
Class Days (circle)
M T W T F S
Time
__________ to __________
Instructor’s Name
Class Start Date
Class End Date
click to sign
signature
click to edit
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