Continuing Education Registration Form
Colleague ID
Last Name
MI
First Name
Last 4 Digits of Social Security Number
Sex
Male
Female
Date of Birth
Age Today
Home Phone
Cell Phone
City
State
Zip
Business Phone
E-Mail Address
Race
White
Black
American Indian
Hispanic
Asian/Pacific
Islander
N.C. Resident?
Ye
s
No
County of Residence
Circle Highest Grade Completed
0 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15 16 17
or if High School Equivalency
Employee Status
F Employed Full-Time
P Employed Part-Time
1 Retired
2 Unemployed, not seeking
3 Unemployed, seeking
IN Inmate
Name of state
(if Non-Resident)
Employer
Firefighter, EMS, or Law Enforcement Affiliation
Location of Instruction (Building, Room)
Term
Summer Fall Spring
Y
ear:
Name of Course
Class Days (Circle)
M T W T F S
Time
to
Instructors Name
Class Start Date
Class End Date
Students Signature
Date
Registration/Payment Information
Fax or mail registration form to:
Continuing Education
Cleveland Community College
137 South Post Road
Shelby, NC 28152
Fax: 704-669-4205
Call 704-669-4015 to make payment for course(s).
Registration and payment must be received one week prior to the start date
of the class. Office hours are Monday Thursday from 8 AM 6 PM and
Friday from 8 AM 4 PM, excluding holidays and semester breaks.
Continuing Education Refund
Policy
The College may refund registration fees under the following circumstances:
1. If a student officially withdraws from the class prior to the first class ses-
sion, the student will receive a 100% refund.
2. If a class is canceled due to insufficient enrollment, the student will
receive a 100% refund.
3. After a class begins and a student officially withdraws from the class
prior to or on the 10% point of the scheduled hours, the student will
receive a 75% refund.
This refund is limited to the registration fee and does not include accident
insurance, liability insurance, textbooks or supplies.
OFFICE USE ONL
Y
Amount of Fees Paid
Date Paid
Institutional Representative
Updated 4/17/18
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome