*The Brunswick Community College Annual Security Report can be found at http://www.brunswickcc.edu/public-safety/.
Datatel # _____________
Contract # _____________
COURSE TITLE:
LOCATION:
START DATE:
HOW DID YOU HEAR ABOUT THIS CLASS?
CHOICES
BCC Website
Social Media
Other ___________
SSN
LAST
FIRST
MI
MAILING ADDRESS
CITY
STATE
ZIP
HOME PHONE:
MOBILE:
COUNTY:
E-MAIL ADDRESS:
DATE OF BIRTH:
Female
Male
White
Black
Hispanic
Asian
Native American
EDUCATIONAL LEVEL
_____ Non Graduate
(Enter highest grade completed 0-11)
High School Graduate
Name of HS ________________
Year _____
GED Diploma
Adult High School Diploma
Vocational Diploma
Associate Degree
Bachelor’s Degree
Master’s Degree or Higher
VETERANS STATUS
Active
Honorable Discharge
Reserves
Retired
Employed
1-10 hours
11-20
21-39
40 or more
Unemployed
Seeking
Not Seeking
Retired
Tuition Fee Waived:
Emergency Services Agency:
____________________________________
Other:
____________________________________
Paid
Volunteer
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.
Self-Supporting classes will refund 75% to the student with an official withdrawal from
the class prior to the start date. No refunds will be issued after the start date of class.
If a student, having paid the required registration fee for a semester, dies during that
semester (prior to or on the last day of examinations of the course the student was
attending), all registration fees for that semester will be refunded to the estate of the
deceased.
PERMISSION TO RELEASE PHOTO FOR PUBLICATION
YES
NO
HRD TUITION AND FEE WAIVER VERIFICATION STATEMENT
The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in classes
coded in the Master Course List/Combined Course Library (MCL/CCL) as Human Resource Development if the
individual meets one of four criteria listed below. To receive this waiver, an individual must verify that he/she
meets at least one of the criteria by completing and signing this form.
I qualify for a tuition and fee waiver under the following criteria:
I am currently unemployed.
I have received notification of pending layoff.
I am working and eligible for the Federal Earned Income Tax Credit.
I am working and earn wages at or below 200% of the federal poverty guidelines.
STUDENT SIGNATURE:
If your check is dishonored or returned for any reason, we will electronically debit your account for the amount of the check plus a processing fee of $25.00
DATE:
CONTINUING EDUCATION, ECONOMIC & WORKFORCE DEVELOPMENT REGISTRATION FORM
VA Benefits can not be used to pay for CEWD courses.
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