RV: AH 03/2020
Public Safety Registration ONLY
3000 Wayne Memorial Drive | Goldsboro, North Carolina 27534 | 919-739-6900 | www.waynecc.edu
Class Title:
Class Start Date:
**Please use Legal Name when completing the form.**
Last Name:
First Name:
Middle Name:
SSN or Student ID:
Birthdate (mm/dd/yyyy):
Mailing Address:
Zip Code:
County of Residence:
Primary Phone:
( )
Phone Type:
Home Cell Phone Business
Other Phone:
( )
Phone Type:
Home Cell Phone Business
Email Address:
Sex: (Check One) Ethnic/Race: (Check at least One)
American/Alaska Native
Black or African American
Hawaiian/Pacific Islander
Asian/Pacific Islander (NP)
(Check One)
Retired Unemployed Seeking
40 or more hours 21 39 hours 11 20 hours 1 10 hours
Occupation: Employer:
Education Level:
(Check or enter the highest grade completed)
Never Attended Highest Grade Completed: Completed High School
Adult High School Diploma GED® or High School Equivalency Diploma One-Year Vocational Degree
Associate Degree Bachelor’s Degree Master’s Degree or Higher
For Public Safety Courses ONLY
My signature attests that I am actively affiliated with the public safety agency listed and that I hold the job classification indicated.
Name of Public Safety Agency/Department/Team:
Job Classification:
Firefighter (Volunteer)
Firefighter (County/State/Municipal)
EMS Responder (Volunteer)
EMS Responder (County/State/Municipal)
Emergency Mgt. Personnel
Named in EOP
Law Enforcement Officer
Detention Officer
DACJJ Certified Officer (Job Title: ___________________________________________)
Sponsored BLET
Other: ___________________________________________
I hereby give permission to Wayne Community College & the NC Department of Community Colleges to release my grades to:
(Please initial on the line below for the appropriate agencies.)
______ NC Department of Insurance Fire/Rescue Commission
______ NC Criminal Justice’s Training and Standards Commission and/or NC Sheriff’s Commission
Supplemental Student Accident Insurance (SSA Ins.): As a registered student of a Workforce Continuing Education Course you
may purchase Supplemental Student Accident Insurance for $0.55 per semester.
I would like to purchase SSA Ins.
I would NOT like to purchase SSA Ins.
(Your signature indicates that all information is accurate, and you have read & understand the Refund Policy.)
Student Signature: _____________________________________________________ Date: ________________________
RCTP # Payment Processed By: Date:
Sponsor ID#:
Payment Type: CASH Check # Money Order #
CREDIT: VISA Mastercard CONF.#:
Class Fee $ Tech. Fee $ ST-ID Fee $ Parking Fee $ SSA Ins. $
Exam/Cert Fee $ Other Fee: $
CID #:
click to sign
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RV: AH 03/2020
The refund policy for 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 officially 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 officially withdraws prior to the first 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
officially registered is cancelled due to the insufficient 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 official 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 significantly 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 file a third-party comment at the time of the institution’s decennial review, or (3) to file a complaint
against the institution for alleged non-compliance with a standard or requirement.
Inquiries about Wayne Community College, such as admission requirements, financial aid, educational programs, etc. should be addressed
directly to Wayne Community College and not the Commission’s office.
The College’s annual safety and security report is available online at www.waynecc.edu/campus-police-and-security/ or in the Office of
Campus Police and Security.
Wayne Community College is an Equal Opportunity/Affirmative 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 qualified 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 Office 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 Office of Admissions and Records and in the Office of Counseling Services.