Fillable Human Resources Development Registration Form 2020 (Vance-Granville Community College)

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Human Resources Development Registration Form 2020 (Vance-Granville Community College)

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Vance-Granville
Community College
Human Resources Development
Registration Form 2020
Student Information
Social Security Number:
Full Name:
Address:
Phone:
Gender: Race:
Class Number:
Class Title:
Student ID #:
Birth Date:
Last First M.I.
Street Address Apartment/Unit #
City County of Residence
State Zip Code
Home: Cell: Business:
Email:
❒
M
❒
F
❒
American/Alaska Native
❒
Asian
❒
Black/African American
❒
White
❒
Hispanic/Latino
❒
Hawaiian/Pacic Islander
Education
High School Graduate?
❒
Yes
❒
No
If No, List the Highest Grade Completed:_______________________
High School Name and Location (For 16-18 years only):
Highest Level of
Education:
❒
GED Diploma
❒
Adult HS
❒
One-Year Vocational Diploma
❒
Associate Degree
❒
Bachelor’s Degree
❒
Master’s Degree or Higher
Employment
Employment Status:
❒ Full-Time ❒ Part-Time ❒ Retired ❒ Unemployed (seeking) ❒ Unemployed (not seeking)
Emergency Contact
Name: Relationship: Phone:
HRD Tuition and Fee Waiver Verication 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 notication 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: ______________________________
Age:
Instructor:
We will request a signature via email and DocuSign after you submit this form.
Criteria Earned Income
Threshold
Individual $15,820
Worker with one qualifying child $41,756
Worker with two qualifying children $47,440
Worker with three or more qualifying children $50,594
FEDERAL EARNED INCOME TAX CREDIT
200% OF THE FEDERAL POVERTY GUIDELINES
Family Unit 200% of
Poverty Guidelines
1 $25,520
2 $34,480
3 $43,440
4 $52,400
5 $61,360
6 $70,320
7 $79,280
8 $88,240
For each additional person, add $4,480
(Actual Guidelines on Federal Register listed at 100%)
2020 HRD Tuition and Fee Waiver Guidelines
Federal Earned Income Tax Credit
https://www.irs.gov/credits-deductions/individuals/earned-income-tax-credit/
earned-income-tax-credit-income-limits-and-maximum-credit-amounts
200% of the Federal Poverty Guidelines: January 17, 2020
https://aspe.hhs.gov/system/les/aspe-les/107166/2020-percentage-
poverty-tool.pdf https://aspe.hhs.gov/poverty-guidelines
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Human Resources Development Registration Form 2020 (Vance-Granville Community College)

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Completed 24 July 2020

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