Last 4 digits of SSN _____ _____ _____ _____ or Student ID Number_____________________________________
Last Name __________________________________ First Name ______________________________________
Address __________________________________ City ___________________________________________
State __________________________________ Zip ____________________________________________
Birthdate __________________________________ Gender Male Female
Home Phone __________________________________ Cell/Mobile ______________________________________
Work Phone __________________________________ Employment Status F/T P/T Unemployed
Race: White Asian Black/African American American Indian/Alaskan Native Native American (circle all that apply)
Are you of Hispanic origin? Yes No
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED 13 14 15 16 17
Please check one: I certify that I am at least 18 years old and not enrolled in public school or
I am under 18 and have provided a Minor Release Form to the Continuing Education office.
By signing below I certify that the given information is completed and correct.
Signature ___________________________________ Date: _________________________________
Please print all informaon
Section Number Course Title Location Registration Fee
Section Number Course Title Location Registration Fee
Selected Payment: MasterCard /Visa
Check
Money Order
To pay with MasterCard or Visa: Go to www.rockinghamcc.edu •Click on Continuing Education •Click Register
Online Here For Continuing Education Courses • Click on Register and Pay for Continuing Education Clas-
ses • Key in Course Code •Then click submit •On the left select the course •Click submit •Complete information
and follow prompts for payment. For Ed2Go payments contact: Sarah Tucker tuckers0514@rockinghamcc.edu
To register, complete this form and mail it along with a check or money order payable to RCC, PO Box 38, Wentworth, NC, 27375. Attn: Business Office,
PLEASE DO NOT SEND CASH.
Section Number Course Title Location Registration Fee
Section Number Course Title Location Registration Fee
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signature
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