Continuing Education
HRD Registration Form and
Fee Waiver Verification
Course Prefix/Number
Beginning Date Ending Date
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.
6/2017
Instructor Name Location
*Last 6 of Social Security # or College ID #
(*Used for reporting purposes only)
Name
Last First Middle
Address
Street, P.O. Box, Route City State Zip Code
County of Residence Date of Birth
Month Day Year
Home PhoneE-mail Address
Check the highest education level that best describes you
11 (Highest Grade Completed - Non-High School Graduate)
-- GED
12 (High School Graduate)
2
1
0
4 - I am working and earn wages at or below two hundred percent (200%) of the
federal poverty guidelines
2 - I have received notification of a pending layoff
3 - I am working and eligible for the Federal Earned Income Tax Credit1 - I am currently unemployed
Tuition and Fee Waiver Verification Statement
* Answer question only if you are qualifying for the fee waiver under criteria "working and eligible for the Federal Earned Income Tax Credit (#3)
Please indicate the number of dependents living in your household: _______________________
I hereby verify that all the information given by me as written on this Registration and Fee Waiver Verification form is complete and accurate to the best of my knowledge.
Student Signature Date
AN EQUAL OPPORTUNITY INSTITUTION
Sex Female
Male
Ethnicity
Non Hispanic/Latino
Hispanic/Latino Race American/Alaska Native
Hawaiian or Pacific Islander
Asian
White
Black or African American
Inmate
Unemployed - Seeking (US)
Unemployed - Not Seeking (UN)
Retired (R)
Part-Time (PT)
Full-Time (FT)
Current Employment Status
4
5
6
7
8
9
10
13 Adult High School Diploma
16 Bachelor's Degree
17 Master's Degree or Higher
Registration FeeCourse Title
15 Associate Degree
14 Post High School Vocational Diploma
Military Status
4 Retired
3 Discharged
2 Reserve
1 Active
Employer & Job Title Start/End Date Weeks Employed Hourly Wage Hours Per Week Comments
Employment History (Start with your current or most recent job)
Johnston Community College does not discriminate in admissions, employment, or in its administration of educational programs and activities on the basis of age, race, color, sex, national origin,
disability, religion, creed, military or veteran status, genetic information, or any other characteristic protected under applicable federal or state law. Inquiries should be addressed to the vice
president of student services or vice president of administrative services. Inquiries concerning the application of Title IX may be referred to the Title IX Coordinator. JCC's Title IX Coordinator is
Bernadette Carter-Dove, whose office is in the Wilson Building, room 1023C. This office can be contacted by phone at (919) 209-2025 or by email at bjcarterdove@johnstoncc.edu.
