SSN ________ ________ ________ or Student ID Number_____________________________________
Last Name ______________________________________ First Name ____________________________________________
Address ______________________________________ City _________________________________________________
State ______________________________________ Zip __________________________________________________
Birthdate ______________________________________ Gender O Male OFemale
Home Phone ______________________________________ Cell/Mobile ___________________________________________
Work Phone ______________________________________ Employment Status O F/T OP/T O Unemployed
Race: OWhite O Asian O Black/African American O American Indian/Alaskan Native O Native American (circle all that apply)
Are you of Hispanic origin? O Yes O No
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 17
Please check one: O I certify that I am at least 18 years old and not enrolled in public school or
O I am under 18 and have provided a Minor Release Form to the Continuing Education office.
By signing below I certify that the given information is completed and correct.
Signature ___________________________________ Date: _________________________________
Secon Number Course Title Locaon Registraon Fee
Secon Number Course Title Locaon Registraon Fee
Selected Payment: MasterCard /Visa
Check
Money Order
To pay with MasterCard or Visa: Go to www.ed2go.com/rockcc. Click Enroll Now, and follow the
prompts. Call with any quesons, 336.342.4261 ext. 2124
To register, complete this form and mail it along with a check or money order payable to RCC, PO Box 38, Wentworth, NC, 27375. An:
Business Oce, PLEASE DO NOT SEND CASH.
Secon Number Course Title Locaon Registraon Fee
Secon Number Course Title Locaon Registraon Fee
Grade_2
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