Continuing Education/HRD Registration Form and Fee Waiver Verification
Please note: this registration and fee waiver form is for HRD/Workforce Development coursesonly.
Last name: First name: ___________________________ MI: _____________
Address: City: State: ZIP: _____________
County: ❒ Please check if this is a new address or change in information.
Home: Business: Ext.: Cell: ______________________
Colleague ID #: (assigned by college if new student) Date of birth: _______________
Email address: _______________________________________________________
Highest education level completed:
Race (Check all that apply)
Gender
☐ Non-graduate (highest grade
☐ American/Alaska native
☐ Female ☐ Male
completed _____)
☐ GED
☐ Asian
☐ Black/African-American
Employment status
☐ Full time (40 or more hours/week)
☐ High school diploma
☐ Hawaiian/Pacific Islander
☐ Part time (39 or fewer hours/week)
☐ Associate’s degree
☐ Hispanic/Latino
☐ Retired
☐ Bachelor’s degree
☐ Non-Hispanic/Non-Latino
☐ Unemployed (not seeking)
☐ Master’s degree or higher
☐ White
☐ Unemployed (seeking)
TUITION AND FEE WAIVER – VERIFICATION STATEMENT
The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in courses coded in the
Master Course List and 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 completing or signing this form must pay the applicable fee to register for a Continuing Education course.
I qualify for a tuition and fee waiver under the following
criteria:
☐ 4. I am working and eligible for the Federal Earned Income Tax
☐ 1. I am currently unemployed.
Credit. Please indicate the number of dependents living in
☐ 2. I have received notification of a pending layoff.
your household:
____
☐ 3. I have never been employed.
☐ 5. I am working and earn wages at or below 200
percent of the federal poverty guidelines.
I hereby verify that all information I have completed on this Registration and Fee Waiver Verification
form is complete and accurate to the best of my knowledge.
Student signature: Date: _____________________
College employee signature: Date: _____________________
11/5/2019
