Johnston Community College
StreetSafe Driving Program
Registration Form
See the enclosed schedule for class dates and corresponding class numbers. Please indicate the class #
(number) for a first and second class selection.
Please register me for the following class. I have enclosed the $120.00 NON-REFUNDABLE
REGISTRATION FEE as indicated.
First Choice Class # __________ Date ____________________
Second Choice Class # __________ Date ____________________
Any student under eighteen (18) years of age must have a Concurrent Enrollment Form on file (unless you are a
Johnston County Public School student) prior to class start date. Additionally, if you are under eighteen (18),
your parent or legal guardian must sign you into your StreetSafe session and stay for the first class hour!!!
Name_________________________________________________________________________________
Please print your name as it appears on your driver's license.
Mailing Address________________________________________________________________________
City___________________ State_____ Zip Code__________ County of Residence________________
Social Security #_____________________________ E-mail Address:_____________________________
For registration purposes only
Date of Birth _________________ Age________________
Drivers License or Learner’s Permit #_______________________________
Court Case Number_________________________ Continued Court Date (if applicable)_______________
Sex ( ) Male ( )Female Race_________ Cell Phone _____________________________
Phone (H)________________________________ (W)___________________________________
Circle Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 or GED ( )
Current High School Attending (if applicable) ___________________________________________________
Employment Status: ( ) Retired ( ) Unemployed ( ) Part Time ( ) Full Time
Employer ___________________________________ Occupation____________________________________
Please read carefully and sign: I understand that classes will be filled based on the order of receipt of completed registration forms
and appropriate fees. A receipt confirming my registration and class number will be mailed. If for some reason my choices of classes
are filled prior to the receipt of my registration form and fee, I will be given the opportunity to either choose another class date and
have my registration transferred, or request that my registration fee be returned to me. Due to program constraints, I understand that
once registered in a class, even if I am unable to attend, the registration fee is non-refundable and non-transferable. I understand
that I must be on time and attend the entire class in order to successfully complete the course.
Additionally, if you are under eighteen (18) your parent or legal guardian must sign you into your StreetSafe session and stay
for the first class hour!!!
I have read the above program policies and understand how these policies apply to my registration.
Signature____________________________________________ Date_______________
Method of Payment: ( ) Certified Check or Money Order (Payable to JCC) _____________
For JCC Office Use:
Contract Number_______________________ Date Received_________________
Program Code__________ AR Code_________
