RANDOLPH COMMUNITY COLLEGE
629 Industrial Park Ave. ~ Asheboro, NC 27205-1009/www.randolph.edu
CONTINUING EDUCATION STUDENT REGISTRATION FORM – MAIL-IN FORM ONLY
NAME (Please Print)
Last First Middle Maiden
Street Address or Post Office
City State Zip County
Home Phone #
Work Phone # Cell #
E-Mail Address:
Social Security Number or your 7 digit Student ID Number
Date of Birth
--
If 65 or older, Check here
Employment Status – Circle One
Ethnic – Circle One
1. White, Non-Hispanic 3. American Indian/Alas 5. Asian or Pacific Island
2. Black, Non-Hispanic 4. Hispanic 6. Other/Unknown
Gender – Circle One
M - Male
F - Female
Circle Highest Grade Completed or check if passed HS Equivalency (GED) 1 2 3 4 5 6 7 8 9 10 11 12 13-Adult HS Diploma
14- One Yr Voc. Diploma 15-Associate Degree 16-Bachelor Degree 17-Master’s Degree or higher
HOW DID YOU LEARN ABOUT THIS CLASS?
_____ PREVIEW/CATALOG _____ OTHER (please specify ___________________________________________________________________)
If registering for a fire, police or emergency service course, list name of department/agency.
Check any or all of the following that apply: I hereby give Randolph Community College and the N. C. Community
Paid Firemen Volunteer Firemen College System permission to release my grades to:
Paid EMS Personnel Volunteer EMS Personnel ____ NC Dept. of Insurance Fire/Rescue Commission
Paid Rescue Sq Volunteer Rescue Sq ____ NC Criminal Justice’s Training & Standards Commission and/or
Paid Law Enforcement HRD Waiver NC Sheriff’s Commission
Dept of Corrections Employee Civil Preparedness Employee
Section Number
Ex: CAS3020A 78000
Section Title
Introduction to Computers
Day(s)
T, Th
Time
6-9 pm
Fees
$55
Location
Main Campus
1.
2.
3.
Please check one:
I certify that I am at least 18 years old ________ or that I am under 18 and have provided a Minor Release Form to the Continuing Education Registration Office __________.
Signature___________________________________________________Date ______________________Amount Paid ________________
Method of Payment: _____ Check Enclosed
FOR CE REGISTRATION ONLY 07/10/07 cdc
E1 - Employed 1-10 Hrs. E4 - Employed 40 or more Hrs US - Unemployed Seeking
E2 - Employed 11-20 Hrs. R - Retired
E3 - Employed 21-39 Hrs. UN - Unemployed – Not Seeking
ame of Employer:_________________________________________________________
