815-599-3414
Registration Form highland.edu
Social Security Number __________ - ______ - __________
According to the IRS standards in regulation section §1.6050S-1 (see section 6723), Highland Community College is required under penalty of perjury to
show we have in good faith complied with Internal Revenue Service (IRS) regulations to solicit for a valid social security number (SSN).
Name_______________________________________
_____________________________________________________
Last First Middle (Required, if none, write N/A)
Address__________________________________________________________________________________________
City_______________ State ______ Zip Code__________ Phone (include area code) ( )___________________
Date of Birth _________________ Sex: ____Male ____Female
1. Are you Hispanic or Latino (OR are you of Spanish
Origin)?
_____ Yes Hispanic or Latino – If yes, skip to # 3.
_____ Not Hispanic or Latino
2. Please identify your primary racial/ethnic group
(Select One)
____ American Indian or Alaska Native
____ Asian
____ Black or African American
____ Hispanic or Latino
____ Native Hawaiian or Other Pacific Islander
____ White
____ Choose Not to Respond
3. Are you from one or more of the following racial
groups? (Select all that apply)
____ American Indian or Alaska Native
____ Asian
____ Black or African American
____ Native Hawaiian or Other Pacific Islander
____ White
____ Choose Not to Respond
4. Are you in the U.S. on a Visa – Non-resident Alien?
____ Yes in the United States on a Visa.
Provide Home Country of Origin
_______________________________________
_____Not in the United States on a Visa
5. Highest Degree Earned _____ Associate
_____ Bachelor’s _____ Master’s _____ Doctorate
6. High School Graduate ______ Yes _____ No
Year ____ School___________ City________________
7. GED _____ Yes _____ No State ________
Course ID # Course Title Cost
$
$
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$
Payment must accompany registration form:
_______ Full Payment by Check (Check # ___________) Make Checks payable to Highland Community College.
_______ Full Payment by Credit Card (Highland will call you for credit card number to process over phone.)
Preferred phone (____)______-________________
As consideration for being permitted by Highland Community College, the State of Illinois (“State”), the County of Stephenson (the “County”), and any
lessor of Highland Community College premises (“Lessor”), to participate in Lifelong Learning courses and use Highland Community College premises and
facilities, I (the undersigned) forever release the College, the State, the County, the Lessor, any Highland Community College affiliated organization, and
their respective directors, officers, employees, volunteers, agents, contractors, and representatives (collectively “Releasees”) from any and all actions,
claims, or demands that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal representatives now have, or may have in the future,
for injury, death, or property damage, related to (i) my participation in these activities, (ii) the negligence or other acts, whether directly connected to these
activities or not, and however caused, by any Releasee, or (iii) the condition of the premises where these activities occur, whether or not I am then
participating in the activities
_______________________________________________________
____
Student’s Signature Date
Mail registration with check to: Attn: Admissions, Highland Community College, 2998 W Pearl City Rd, Freeport, IL 61032
&UHDWLYH7HFK&DPSVSOHDVHFRPSOHWHSDJH
Course fees are refundable when a course is
canceled by the College. Fees are refundable to
the student whose written request for withdrawal
has been received by the Office of Admissions
and Records prior to the beginning of the class.
