q Check if this is a change in name, address or employer.
Section Number: Start Date: Time: Room:
Course Title:
Student Social Security Number: - - Student ID:
Last Name: First Name: Middle/Maiden:
City: State: Zip:
County Residence: County Code:
Home/Work Phone: Cell Phone:
Email Address:
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:
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 Bachelors 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: $
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.
NCELLATIONS A course may be canceled if fewer than 10 enroll.
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
Wilson Community College and its faculty are committed to supporting our students and seeking an environment that is free of
bias, discrimination, and harassment. The College prohibits any form of unlawful discrimination, harassment, or violence, including
sexual assault, domestic violence, dating violence, stalking, and hate crimes based on sexual orientation, gender identity, and
nationality. If you have encountered any form of sexual misconduct (e.g. sexual assault, sexual harassment, stalking, domestic
or dating violence), or gender-based discrimination, we encourage you to report this to the College. If you speak with a faculty
member about an incident of misconduct, that faculty member must notify the Title IX Coordinator (see contact information below).
The Title IX Coordinator will then be available to assist you in understanding all of your options and in connecting you with all
possible resources on and o
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 students 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
To request accommodations as a pregnant or parenting student, contact:
Jesse Sykes, Title IX Administrator
Oice: F-100b • Phone: (252) 246-1230 • Email: js4693@wilsoncc.edu
Accommodations cannot be approved until the oicial documentation form from the Title IX Administrator is received by the
instructor. Accommodations are not retroactive.
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 therefrom, or denied accommodation, the student should file a report to either of the
resources below:
Kathy Williamson, Title IX Coordinator
Oice: C-106 • Phone: (252) 246-1263 • E-mail: kw9934@wilsoncc.edu
OR in Mrs. Williamson’s absence:
Joshua Harris, Deputy Title IX Coordinator
Office: F-103i • Phone: (252) 246-1257 • Email: jh2810@wilsoncc.edu
Keep this page for your records.