Fillable DEVELOPMENT REGISTRATION FORM (Bladen Community College)

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DEVELOPMENT REGISTRATION FORM (Bladen Community College)

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www.bladencc.edu An Affirmative Action/Equal Opportunity Institution
Section No _________
PO Box 266 Dublin, NC 28332 Telephone 910.879.5568 or 5561 Fax 910.879.5569
COURSE NUMBER
COURSE TITLE
☐ Day
☒
SECTION NO
START DATE
SSN/BCC NO
LAST
FIRST
MI
MAILING ADDRESS
CITY
ZIP
HOME PHONE
CELL
COUNTY
E-MAIL ADDRESS
DATE OF BIRTH
M-
D-
Y-
☐ Female ☐ Male
☐
White
☐
Black
☐
Hispanic
☐
Asian
☐
Native American
☐
Other
EDUCATIONAL LEVEL
_____ Non Graduate
(Enter highest grade completed 0-11)
☐ High School Graduate
☐ HSE Diploma
(High School Equivalency)
☐ Adult High School Diploma
☐ Vocational Diploma
☐ Associate Degree
☐ Bachelor’s Degree
☐ Master’s Degree or Higher
HEAD OF HOUSEHOLD
☐ Yes ☐ No
Employed
☐ 1-10 hours
☐ 11-20
☐ 21-39
☐ 40 or more
Unemployed
☐ Seeking
☐ Not Seeking
☐ Retired
Tuition Fee Waived
Emergency Services Agency
____________
________________________
☐
Paid
☐Volunteer
Authorized Group or Organization
(job classification)
☐
Firefighter (Vol Agency)
☐ EMS Responder (Vol Agency)
☐ Emergency Mgt. Personnel
☐ Telecommunicator/Dispatcher
☐ Sponsored BLET
☐ DACJJ Certified Officer
(Note:
Student must indicate title for DACJJ;
See appendix in Waver Reference Guide
for eligible Corrections /JJ job titles.)
☐
Firefighter
(County/State/Municipal Agency)
☐ EMS Responder (County/State Municipal Agency)
☐ Named i
n EOP______________________
☐ LE Officer
☐ Detention Officer
☐ Other ____________________________
My signature attests that I am actively affiliated with the public safety agency listed above and that
I hold the job classification indicated.
Student Signature: Date:
TUITION REFUND POLICY
Refunds are allowed under the following circumstances:
• A student who officially withdraws, in writing, from an occupational extension class prior to the first class meeting or if a class is cancelled shall be eligible for a 100%
refund.
• After class begins, 75% shall be refunded at the request of the student if the student officially withdraws, in writing, from the class prior to or at the 10% point of the
scheduled hours of the class. Note: This rule is applicable regardless of the number of times the class meets or the number of hours the class is scheduled to meet.
• For contact hour classes, students must withdraw, in writing, within 10 calendar days.
• Registration fees for self-supporting classes are non-refundable once the class begins.
Office Use Only Method of Payment
$
Course Fees
Cash
☐
Credit Card
☐
Check:
☐
$ Total Collected Third Party Billing
Person Receiving Payment Receipt No.
CONTINUING EDUCATION, ECONOMIC & WORKFORCE
DEVELOPMENT REGISTRATION FORM
RGPE
ASPR
XNCA
RGN
ARAI
Eve
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DEVELOPMENT REGISTRATION FORM (Bladen Community College)

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Completed 26 July 2020

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