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Workforce Development & Business Division
Adult & Youth Workshop Registration
Student ID or J# ___________________ Date ______________________
First Name________________________ Last Name________________________________
Date of Birth (mm/dd/yy) ___________________ Male Female
Have you ever taken a JCC class? Yes No If yes credit non-credit Former Name? ___________________
Mailing Address _________________________________City____________________State ______ Zip _______
Home Phone ( ) ____________________________ Business Phone ( ) ___________________________
Cell Phone ( ) ______________________________ Email Address _________________________________
How did you hear about our workshop(s)? ______________________
Would you like an emailed Certificate of Completion? Yes No
If Registering a Minor:
Emergency Contact_____________________________ Relationship ___________________ Phone_____________________
List allergies/medical conditions we should be aware of:_________________________________________________________
Parent/guardian Signature: _______________________________
Course Code
ex: CED 007 701
Third Party Payment
Name:
Address:
Phone:
(Circle Payment Method)
Personal Check/Cashier’s Check (payable to Jefferson Community College) OR Visa/MasterCard/Discover/American Express
Name on Card________________________________________________________
Card No. ____________________________________________________________
Exp. Date _________ 3 Digit Security Code (CVS) __________
Workforce Development & Business Division, Extended Learning Center, Suite E-100, 1220 Coffeen Street Watertown, NY 13601
Phone: 315-786-2233 / Fax: 315-786-2391 / Email: ced@sunyjefferson.edu
I grant permission for JCC to use an image of myself and/or the image of my minor child in printed & electronic/social media marketing.
Initial here________________ Name of school child attends, or homeschool___________________________________________
Policy: Registration with payment secures a seat in the classroom. To receive a full refund, registrant must call 315-786-2233 within 24 business hours
(Mon. – Fri.) of the start date. No refund after start date. Workforce Development and Business Division reserves the right to make changes to workshop
date/time and cost(s). If cancelled by the college, registrant will receive a 100% refund. For inclement weather updates call: 786-6565. The general rule
for inclement weather is if campus is closed, the workshop is cancelled.
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