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(please specify)
In case of an emergency, please contact:
NAME _______________________________________________________________________________ PHONE ______________________
____________________________________________________________________________________________________________________
STUDENT SIGNATURE (required) Date
COURSE INFORMATION
Course No. ________________ Section No. __________________ Title _______________________________________________
Instructor ____________________________________________ Location _____________________ Contact Hours ___________
Beginning Date ________________ Ending Date ________________ M T W Th F Sa Su Time ________________________
SOUTH PIEDMONT COMMUNITY COLLEGE COURSE RECEIPT
$ _________________ Registration Fee
$ ________________ Books $ _____________ Other $ _______________ See Attachment
$ ________________ Total Charges billed to Sponsoring Agency _________________________ Contract Training _____________
$ ________________ Total Charges to Student
Amount Paid $ ___________________ by: Student Other: _____________________________________________________
Cash __________ Check # ___________ Credit Card: VISA MC AMEX Discover Approval Code ___________
Comments: ________________________________________________________________________________________________________________
If student is exempt from registration fee, state reason: Vol. Fire Paid Fire Vol. Rescue Paid Rescue Law Employee
Inmate Senior (65+) HRD Correctional Ocer Other _________________
Received by: ________________________________________________________________________________________________________________
College Ocial’s Signature Date
L.L. POLK CAMPUS • PO Box 126 • Polkton, NC 28135 • 704.272.5300 | LOCKHART-TAYLOR CENTER • 514 N. Washington St. • Wadesboro, NC 281705 • 704.272.5300
OLD CHARLOTTE HIGHWAY CAMPUS • 4209 Old Charlotte Hwy. • Monroe, NC 28110 • 704.290.5100
TYSON FAMILY CENTER FOR TECHNOLOGY • 3509 Old Charlotte Highway, Monroe, NC 28110 • 704.290.5100
| www.spcc.edu
02.28.19
NON-CREDIT REGISTRATION FORM
Social Security Number or SPCC Student ID:
___________________________________________________
Last Name ________________________________________________
First Name __________________________________ MI ________
Address __________________________________________________
City _____________________________________________________
State ______________________________ Zip _________________
County of Residence ________________________________________
Phone H ______________________ W _____________________
Are you Hispanic or Latino? Yes No
If no, select one or more races: American Indian or Native Alaskan
Asian Black or African American
Native Hawaiian or other Pacic Islander White
Employment Status
Full-time Part-time ( _____ hours per week)
Retired Unemployed-Not Seeking Unemployed-Seeking
Highest Education Level
Non-Graduate (Highest grade completed __________ )
GED
High School Graduate
Adult High School Diploma
One-Year Vocational Diploma
Associate Degree
Bachelors Degree
Cell _______________________________________________
Master’s Degree or Higher
Date of Birth ______________________________________________
E-mail
___________________________________________________
Sex Female
Male
If course is Emergency Service: Name of Police, Fire or Rescue Dept. _______________________________________ Paid Volunteer
Newspaper Flyer Schedule
On-line Other ____________
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