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DIVISION OF CONTINUING EDUCATION REGISTR ATION (Wilson Community College)

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DIVISION OF CONTINUING EDUCATION REGISTR ATION
q Check if this is a change in name, address or employer.
Section Number: Start Date: Time: Room:
Course Title:
GENERAL INFORMATION
Student Social Security Number: - - Student ID:
Last Name: First Name: Middle/Maiden:
Address:
City: State: Zip:
County Residence: County Code:
Home/Work Phone: Cell Phone:
Email Address:
Birthdate:
Sex: q Male q Female
Ethnicity: q Hispanic/Latino q Not Hispanic/Latino
Race (check one or more): q American Indian or Alaska Native q Asian q Black or African American
q Native Hawaiian or Pacific Islander q White
Employment Status: q Full-Time q Part-Time q Unemployed q Retired
Employer: Occupation:
EDUCATIONAL INFORMATION
Highest Educational Level Completed (check one): q 1 q 2 q 3 q 4 q 5 q 6 q 7 q 8 q 9 q 10 q 11 q 12 q GED
q Adult High School Diploma q College Vocational Diploma q Associate Degree q Bachelor’s Degree q Masters Degree q Doctorate
q Yes q No
Are you currently suspended or have been expelled from another college or educational entity for non-academic disciplinary reasons?
If yes, you will need to see the Executive Dean of Continuing Education prior to registering.
q Yes q No
Marketing Notice: I give Wilson Community College permission to use my photo/video/voice or written statement for marketing purposes
through print, electronic or social media, unless otherwise stated at the time of image collection.
Student Signature: Date:
College Representative Signature:
Law/Fire/Rescue (agency name):
Registration Fee: $
Registration Fee Waived: q Yes q No
Technology Fee: $ Security Fee: $ Total Amount Paid: $
REGISTRATION INFORMATION
REFUNDS For Occupational Extension classes, a 100% refund shall be made if the student withdraws prior to the first class meeting. A 75% refund shall be made if the student withdraws from
the class prior to the oicial 10% point of the class. Requests for refunds must be made by completing a Continuing Education course withdrawal form prior to the 10% point of the class. Forms
are available in the Continuing Education oice (B-105). No refunds are granted for Self-Supporting courses once the class has started. For classes canceled by the College, a full refund shall be
made. You do not have to request a refund in these cases. Please allow 3 - 5 weeks for processing refunds. No refunds shall be made after the 10% point of the class.
COURSE REPEATS A student enrolling in the same Occupational Extension course more than twice within a five-year period will pay the full student cost. Details of these charges are available in
the Continuing Education Oice. This provision is waived if course repetition is required for certification or licensure.
CANCELLATIONS A course may be canceled if fewer than 10 enroll.
CONSUMER INFORMATION
Consumer information is available to all students and prospective students in keeping with the requirements established by the Higher Education Opportunity Act. General information about the
College including financial assistance; the annual campus crime report; retention, transfer and completion rates; and FERPA rights are available.
This information may be accessed on the College’s website under the Campus Information link. Paper copies are available upon request in the Registration Center in Building F or the
Continuing Education Oice in Building B during daytime business hours. Paper copies are available from the switchboard in Building B during evening hours.
Mail completed form to: Division of Continuing Education • Wilson Community College • PO Box 4305 • Wilson, NC 27893
08/2020
DIVISION OF CONTINUING EDUCATION REGISTR ATION
NOTICE OF NONDISCRIMINATION:
Wilson Community College (WCC) is committed to providing programs and activities in an environment free from discrimination and harassment. The College does not
discriminate on the basis of race, color, national origin, sex, sexual orientation, gender, gender identity, gender expression, pregnancy, disability, age, religion, veteran status (or
any other characteristic or status protected by applicable local, state, or federal law), in admission, treatment, or access to, or employment in, its programs and activities.
Inquiries concerning discrimination or harassment based on a protected characteristic or status other than sex or gender may be referred to Executive Dean of Student
Development (for students), or the Director of HR (for employees). Individuals may also make inquiries regarding discrimination or harassment to the U.S. Department of
Education’s Oice for Civil Rights by contacting the District of Columbia Oice, 400 Maryland Avenue, SW, Washington, D.C. 20202-1475; Phone 800-421-3481; email: OCR@ed.gov.
TITLE IX STATEMENT:
Any form of unlawful discrimination, including sexual assault, sexual harassment, domestic violence, dating violence, stalking, and hate crimes based on sexual orientation
or gender identity is prohibited. WCC is also committed fostering a community that promotes prompt reporting and fair and timely resolution of those behaviors. If you have
encountered any form of gender-based discrimination or sexual misconduct, we encourage you to report this to the Title IX Coordinator. Any person (whether or not alleged to be
the victim) may report sex discrimination or sexual harassment, in person, by mail, by telephone, by electronic mail, or by any other means that results in the Title IX Coordinator
receiving the person’s verbal or written report. If the Title IX Coordinator is not available, reports should be made to the deputy Title IX Coordinator.
Title IX Coordinator – Cindy Allen
Phone: (252) 246-1263
Email: callen@wilsoncc.edu
Oice: C106
Deputy Title IX Coordinator – Joshua Harris
Phone: (252) 246-1257
Email: jharris@wilsoncc.edu
Oice: F103i
In addition to the Title IX Coordinator, the College has designated individuals with the authority to institute corrective measures on behalf of Wilson Community College.
Accordingly, these employees are required to report discrimination and harassment on the basis of sex to the Title IX Coordinator:
Vice President for Academic Aairs – Rob Holsten
Phone: (252) 246-1254
Email: rholsten@wilsoncc.edu
Oice: B101a
Vice President of Finance/Administrative Services – Jessica Jones
Phone: (252) 246-1221
Email: jsjones@wilsoncc.edu
Oice: F104
Executive Dean of Student Development – Amy Noel
Phone: (252) 246-1275
Email: anoel@wilsoncc.edu
Oice: F103e
TITLE IX AND PREGNANCY:
Title IX also provides for equal educational opportunities for pregnant and parenting students. It prohibits educational institutions from discriminating against students based on
pregnancy, childbirth, false pregnancy, termination of pregnancy, or recovery from any of these conditions. It also prohibits schools from applying any rule related to a student’s
parental, family or marital status that treats students dierently based on their sex.
Title IX requires the College to excuse a student’s absences with medical approval, due to pregnancy, including recovery from childbirth. The College may oer the student
alternatives to making up missed work, such as retaking a semester, taking part in an online course, or allowing the student to finish at a later date. The student should be
allowed to determine how coursework will be completed.
To request accommodations as a pregnant or parenting student, contact:
Special Populations Counselor – Jesse Sykes
Phone: (252) 246-1230
Email: js4693@wilsoncc.edu
Oice: F-100b
Accommodations cannot be approved until oicial documentation is provided to the Special Populations Counselor and the instructor is notified.
If a pregnant student or parenting student is discriminated against on the basis of sex, including a student’s pregnancy, childbirth, false pregnancy, termination, or recovery from,
or denied accommodations, the student should file a report to either of the employees below:
Title IX Coordinator – Cindy Allen
Phone: (252) 246-1263
Email: callen@wilsoncc.edu
Oice: C106
Deputy Title IX Coordinator – Joshua Harris
Phone: (252) 246-1257
Email: jharris@wilsoncc.edu
Oice: F103i
Keep this page for your records.
08/2020
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DIVISION OF CONTINUING EDUCATION REGISTR ATION (Wilson Community College)

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Completed 3 February 2021

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