Register me for:
Course Title Start Date End Date Time Location
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 ______________________________________________________________________________________________________________________________________________
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 White Black Amer. Indian Hispanic Asian Other
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 Other _______________________________
No Affiliation Department of Affiliation ____________________________________________________________________________________________________
“My signature attests that I am actively affiliated with the public safety agency listed and I hold the job classification indicated.”
I agree disagree to let the Mitchell Community College use photos of me taken in the classroom or on campus for marketing purposes.
REQUIRED: Student Signature __________________________________________________________________ Date _____________________________________________
Registration is taken M-Th, 9 a.m. to 4 p.m. Please register at least three days prior to the course starting date.
Registration is not complete until payment is received. Call (704) 878-3290 to provide credit card information.
MITCHELL USE ONLY Waiver Code ________________ Registration $ __________________ Tax __________________ Total ____________________________
Payment Rec. By _________________________________ Date ____________________ Amt. Paid _______________________ Receipt # _______________________
Cash Check ______________________________Bill to _________________________________________________________________________________________
MCC-218A Equal Opportunity College/Affirmative Action Employer Rev. 01/16
Continuing Education Registration Form
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 officially withdraw from a course prior to its beginning will receive
a full refund.
Participants who officially 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.
(Mitchell Use Only)