Student Registration Defensive Driving
SIGNATURE: DATE:
By signing this form, student agrees the information above is true and accurate and the legal residence given for tuition purposes
is as shown. Student agrees to abide by the HCC Policies and Procedures and the Student Code of Conduct. Unprofessional
behavior can place student’s participation in jeopardy and will be viewed as grounds for dismissal. A complete guide to conduct
can be viewed here: http://www.haywood.edu/policies_and_procedures/policy/6/7 Student agrees to allow HCC to publish
photographs, video footage and personal information pertaining to news releases or other publications or media normally
considered to be that of a two-year college unless a disclaimer has been filed with the Director of Enrollment Management.
Please turn the page over to complete the registration form
Student Information
Payment and Registration for Defensive Driving must be done in person. Registration will end the Thursday
before each class. Anyone registering after this date will need approval from the Dean of Workforce Continuing
Education.
Last Name
First Name
M. I.
Maiden Name
Mailing Address
City
Zip Code
County
Primary Phone
Secondary Phone
Business Phone
Date of Birth (MM/DD/YYYY)
Gender
Male Female
Social Security Number (Required by NCDMV)
Are you a full time NC resident?
Yes No
High School Name
Employment Status
Retired (R)
Unemployed not seeking (UN)
Unemployed Seeking (US)
Employed 1 10 Hours (E1)
Employed 11 20 Hours (E2)
Employed 21 39 Hours (E3)
Employed 40 or more hours per week (E4)
Ethnic Origin
Hispanic/Latino
Non-Hispanic
Select One or More Races:
American/Alaska Native
Asian
Black or African American
Hawaiian/Pacific Islander
White
Prefer not to disclose
Check the highest grade completed
1
2
3
4
5
6
7
8
9
10
11
12
High School Graduation Date
GED
Adult High School
1-Year Vocational Diploma
Associates Degree
Bachelor’s Degree
Master’s Degree or Higher
E-mail Address
Course Information
Course Number
Course Title
Cost of Class
Fees
Student Registration Defensive Driving
Driver’s License Number: State issued:
Reason for taking the class (IE Citation, education, safety)
If you are taking the class due to a citation, what was the citation for?
Court Date: County/State where citation occurred:
(For Office Use Only) Verified in H&SC by Date Colleague ID
Entered in Colleague by Date
For more information on HCC’s Continuing Education Courses please visit our website at:
https://www.haywood.edu/instruction/workforce-continuing-education
Contact Us
General Information
Scott Sutton
828-565-4241
rssutton@haywood.edu
Dean of Workforce Continuing Education
Doug Burchfield
828-564-5128
ddburchfield@haywood.edu
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