Continuing Education Registration Form
Register me for:
Course Title Start Date End Date Time Location
Course ID
(Mitchell Use Only)
Have you taken a class at Mitchell before?
No, provide complete Social Security # _____________________________________________________________________________________
Yes, provide the last four digits of your Social Security # _______________ OR Datatel Student ID # ________________________
Name Last _________________________________________ First _____________________________ Middle______________________ Maiden __________________________________
Mailing Address _____________________________________________ City ________________________________ State __________ Zip _____________
Home Phone ___________________________________________________ Cellphone _________________________________________________________
Business Phone ________________________________________________ Fax ________________________________________________________________
Personal Email _________________________________________________ Work Email _______________________________________________________
Date of Birth ___________________________________________________ Gender Male Female
Ethnicity Hispanic American/Alaska Native Asian Black or African-American
Hawaiian/Pacic Islander White Asian/Pacic Islander
Employment Status Full-time Part-time Unemployed Retired
Employer ________________________________________________________ Occupation _______________________________________________________
Highest Education Level Completed
0 1 2 3 4 5 6 7 8 9 10 11 12 High School Equivalency or GED Diploma
One-year College/Vocational Training Associate Degree Bachelor’s Degree Master's Degree Doctorate Degree
Please check any or all that may apply:
Paid Fireman Volunteer Fireman Law Enforcement Paid Rescue Volunteer Rescue No Aliation
Other _________________________ Department ________________________________ Classication _______________________________________
“My signature attests that I am actively aliated with the public safety agency listed and I hold the job classication indicated.
I agree disagree to let Mitchell Community College use photos of me taken in the classroom or on campus for marketing
purposes.
REQUIRED: Student Signature __________________________________________________________________ Date ____________________________
MITCHELL USE ONLY Waiver Code _______________ Registration $ ______________________ Tax ________________________ Total _______________________
Payment Rec. By ______________________________________ Date ________________________________ Amt. Paid _________________ Receipt # __________________
Cash Check ____________________________________ Credit Card _______________________________ Bill to _________________________________________
Mail, fax or deliver to:
Mitchell Community College, Attn: Registration Desk
701 West Front Street, Statesville, NC 28677
(704) 878-3220 Statesville
(704) 663-1923 Mooresville
(704) 878-4271 fax
Mitchell Community College Cancellation and Refund Policy
The College reserves the right to cancel a class due to lack of enrollment. In this
case, preregistered/prepaid students will receive a full refund.
Preregistered/prepaid students who ocially withdraw from a course prior to its
beginning will receive a full refund.
Participants who ocially withdraw from a course prior to the 10% point will receive
a 75% refund.
Participants who withdraw from a course after the 10% point are ineligible for a
refund.
MCC-218 Equal Opportunity College Rev. 12/19
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