Human Resources Development
Registration Form 2020
Social Security Number:
Student ID #:
Last First M.I.
Street Address Apartment/Unit #
City County of Residence
State Zip Code
Home: Cell: Business:
High School Graduate?
If No, List the Highest Grade Completed:_______________________
High School Name and Location (For 16-18 years only):
Highest Level of
One-Year Vocational Diploma
Master’s Degree or Higher
❒ Full-Time ❒ Part-Time ❒ Retired ❒ Unemployed (seeking) ❒ Unemployed (not seeking)
Name: Relationship: Phone:
HRD Tuition and Fee Waiver Verication Statement and Signature
The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in classes coded in the Master Course List as
Human Resources Development if the individual meets one of four criteria listed below. To receive this waiver, an individual must verify that he or she
meets at least one of the criteria by completing and signing this form. Individuals not signing this form must pay the applicable fee to register for a
Continuing Education course.
I qualify for a tuition and fee waiver under the following criteria: (PLEASE CHECK ONE OPTION)
_________ 1 = I am currently unemployed.
_________ 2 = I have received notication of a pending layoff.
_________ 3 = I am working & eligible for the Federal Earned Income Tax Credit.
_________ 4 = I am working & earn wages at or below two hundred percent (200%) of the Federal Poverty Guidelines.
I hereby verify that all the information given by me as written on this Registration Form and on this HRD Tuition and Fee Waiver Statement is
complete and accurate to the best of my knowledge.
Signature: _____________________________________________________________________ Date: ______________________________
We will request a signature via email and DocuSign after you submit this form.