My signature indicates that all information is accurate, and I have read and understand the Refund Policy.
Student Signature: Date:
Class Title: Class Start Date:
Last Name: First Name: Middle Name:
Address: County (Residence):
City: State: Zip Code:
Primary Phone: ( ) Phone Type: Home Business Cell Phone
Other Phone: ( ) Phone Type: Home Business Cell Phone
E-mail Address:
Student ID or SSN: Birthdate (mm/dd/yyyy):
Sex: (Check One) Ethnic/Race: (Check one)
Male American/Alaska Native Asian Black or African American
Female Hawaiian/Pacic Islander Hispanic White
Employment Status: (Check one) Retired Unemployed - Seeking
Employed: 40 or more hours 21-39 hours 11-20 hours 1-10 hours
Occupation: Employer:
Education Level: (Check or enter the highest grade completed)
Highest Grade Completed: Completed High School Adult High School Diploma
GED® or High School Equivalency Diploma One-Year Vocational Degree
Associate Degree Bachelors Degree Masters Degree or Higher
RCTP #: Payment Processed By: Date: Sent to Business Ofce By: Date:
Payment Type: Check # MO # Cash Credit - CONF #:
Course Fee: $ Technology Fee: $ Student ID Fee: $ Parking Fee: $ Insurance Fee: $
Exam/Cert. Fee: $ Meal Fee: $ Other Fee: $
Human Resources Development (HRD) Courses ONLY - HRD Verication Statement - Tuition and Fee Waiver
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 (HRD) if the individual meets one of the 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 Workforce
Continuing Education course.
I qualify for tuition and fee waiver under the following criteria:
Currently unemployed. Working and eligible for the Federal Earned Income Tax Credit.
Received notication of a pending layoff. Working and earn wages at or below 200% of the federal poverty guidelines.
My signature veries that all the information given by me as written on this HRD Tuition and Fee Waiver Verication information is complete and
accurate to the best of my knowledge.
SUPPLEMENTAL STUDENT ACCIDENT INSURANCE: As a registered student of a Workforce Continuing Education Course you may
purchase Supplemental Student Accident Insurance for $0.55 per semester.
Yes – I would like to purchase Supplemental Student Accident Insurance.
No – I would NOT like to purchase Supplemental Student Accident Insurance.
3000 Wayne Memorial Drive | Goldsboro, North Carolina 27534 | 919-739-6900 | waynecc.edu
click to sign
click to edit
RV: JM8/2017
The refund policy for Workforce Continuing Education Services courses, as established by the N.C. General Assembly, allows a 75
percent refund, after the respective class begins, upon the request of the student if the student ofcially withdraws from the class
prior to or on the 10 percent point of the scheduled hours of the class.
A 100 percent refund shall be made if the student ofcially withdraws prior to the rst day of class of the academic semester or
term as noted in the college calendar. Also, a student is eligible for a 100 percent refund if the class in which the student is ofcially
registered is cancelled due to the insufcient enrollment.
There are no refunds for self-supporting classes. Under this policy, the college shall notify the student of the right to receive a refund
at the time of ofcial withdrawal.
For more information about our graduation rates, the median debt of students who completed the program, and other important information, please
visit our Web site at, http://www.waynecc.edu/gainful-employment/.
Wayne Community College is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate
degrees. Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097, 404-679-4500, http://www.sacscoc.org, for
questions about the accreditation of Wayne Community College.
The Commission on Colleges may be contacted only if there is evidence that Wayne Community College is signicantly non-compliant with a
requirement or standard. Accreditation standards are located at: http://www.sacscoc.org/principles.asp
The purpose for publishing the Commission‘s access and contact numbers is to enable interested constituents (1) to learn about the accreditation
status of the institution, (2) to le a third-party comment at the time of the institution’s decennial review, or (3) to le a complaint against the
institution for alleged non-compliance with a standard or requirement.
Inquiries about Wayne Community College, such as admission requirements, nancial aid, educational programs, etc. should be addressed
directly to Wayne Community College and not the Commission’s ofce.
The College’s annual safety and security report is available online at www.waynecc.edu/campus-police-and-security/ or in the Ofce of Campus
Police and Security.
Wayne Community College is an Equal Opportunity/Afrmative Action College and accommodates the needs of individuals with disabilities. It is
the intent of the College that all programs and activities be accessible to all qualied students. It is the student’s responsibility to make his or her
disability known as soon as the need becomes known in order to provide ample time for arrangements to be made. The student must request
academic adjustments by contacting the Disability Services Counselor in the Wayne Learning Center building, 919-739-6729.
Student Right-to-Know: Information regarding the persistence rate of enrolled students toward graduation and transfer-out-rate is available in the
Ofce of Admissions and Records. Student rights under FERPA are available at http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html or in the
Ofce of Admissions and Records and in the Ofce of Counseling Services.