
 

 

 

 

     
   
 






  
  

   
  




For Business Office Use Only
WTCE
REGISTRATION
COURSE NAME SECTION/ID NUMBER COURSE DATE/S
COURSE TIME COURSE LOCATION COURSE DAYS
INSURANCE
For Office Use Only
INSTRUCTOR SEMESTER BILL TO
For Office Use Only
WORKFORCE, TECHNOLOGIES, & COMMUNITY EDUCATION REGISTRATION FORM
SOCIAL SECURITY # / STUDENT ID
LAST NAME FIRST NAME MIDDLE NAME
HOME ADDRESS: STREET ADDRESS CITY STATE ZIP COUNTY
TELEPHONE NUMBER
DATE OF BIRTH (MO/DD/YYYY)
GENDER (CHOOSE ONE) ETHNIC (CHOOSE ONE)
HOME:
WORK:
CELL:
(MONTH) (DAY) (YEAR)
MALE FEMALE
WHITE
BLACK
HISPANIC
AMERICAN INDIAN/ NATIVE
ASIAN/PACIFIC ISLANDER
OTHER/UNKNOWN/MULTIPLE
EMPLOYMENT HIGHEST GRADE COMPLETED
R Retired
E1 Employed 110 hrs per wk UN Unempnot seeking emp
E2 Employed 1120 hrs per wk US Unempseeking emp
E3 Employed 21-39 hrs per wk
E4 Employed 40 or more hrs per wk
0 1 2 3 4 5 6 7 8 9
10 11 12 GED 13AHS
141 yr Voc Diploma 152 yr Associate Deg
164 yr Bachelors Deg 17Masters/Higher
**TUITION WAIVER CHECK IF APPLICABLE
HOW DID YOUR HEAR ABOUT THIS CLASS?
CEPFR –Paid Fireman
CEVFR –Volunteer Firemen
CEPRS –Paid EMS/Rescue Squad
CEVRS –Volunteer EMS/Rescue Squad
CEPLW –Paid Law Enforcement
CECPR –Paid County School Employee
CEPSMCE EMS Military Personnel
Newspaper/Radio/TV___________________________
Employer ____________________________________
Other _______________________________________
SCC Website/Internet Family/Friend
Surry Co. Workforce Center Creating Success
STUDENT SIGNATURE STUDENT EMAIL ADDRESS DATE
DRIVER’S LICENSE NUMBER SIGNATURE OF WTCE REPRESENTATIVE
COURSE TUITION TECHNOLOGY FEE
TOTAL CHARGES
CASH/MONEY ORDER TUITION WAIVER [Check the appropriate waiver in the above waiver section (**)]
CHECK‐ MAKE CHECK PAYABLE TO SURRY COMMUNITY COLLEGE PLEASE INCLUDE DRIVER’S LICENSE NUMBER ON CHECK
DEBIT CARD - TYPE OF CARD:
VISA MASTERCARD
EXP. DATE (MONTH/YEAR):
CREDIT CARD - TYPE OF CARD:
VISA MASTERCARD
EXP. DATE (MONTH/YEAR):
CARD #:
(Debit/Credit)
SECURITY #:
(ON REVERSE SIDE OF CARD)
STUDENT SIGNATURE FOR DEBIT/CREDIT CARD
PAYMENT OPTIONS
FEES
FEES
FEES
FEES
/
/
-
-
-
-
FT Full-time employed
PT Part-time employed
DISCOVER
AMERICAN EXPRESS
Rank/Title:_____________________________
Agency:________________________________
Workforce, Technologies, & Community Education Division ~ 630 South Main Street ~ Dobson ~ North Carolina ~ 27017 ~ www.surry.edu
Important Student-Related Policies
Any person eighteen years of age or older may be admitted to any Workforce, Technologies, & Community Education class.
Sixteen and seventeen year olds may also enroll in Workforce, Technologies, & Community Education courses. Sixteen and
seventeen year olds may be admitted in a Basic Skills class if they submit a Surry Community College student release form which
documents school approval and parental consent.
A student who wishes to withdraw from a Workforce, Technologies, & Community Education course must contact the corporate
and continuing education office prior to or on the 10% point of the scheduled hours of the class to be eligible for a refund. A 75%
refund will be given if the student requests the refund in a timely manner.
Some policies regulating student behaviors are necessary on any college campus. When you register for one or more classes at SCC, you
must agree to abide by all of its policies, and you document this agreement, as well as your receipt of the information below, by your signature
on the front of this form. Complete copies of these policies are available in the Student Development Office and will be provided to you upon
request. Listed below are summaries of some of the most important ones. Please consult the Vice President for Student Development for
additional information and/or clarification of any policies.
Drug-Free Student: Drug use and abuse by students has become an immediate concern in our society. Drug users may endanger other
students and the college educational environment. Therefore, it is the policy of Surry Community College that the manufacture, distribution,
dispensation, possession or use of a controlled substance is prohibited while on college grounds. Use of any drug authorized by medical
prescription from a registered physician is not considered a violation of this rule. However, students will be held strictly accountable for their
behavior while under the influence of prescribed medicines.
Information Technology Acceptable Use: Electronic information technology systems are essential tools for learning and research provided
for student use. It is the policy of the college that the facilities be used ethically and legally, in accordance with applicable licenses and
contracts, and according to their intended use for educational purposes in support of the college’s mission and goals. Examples of specific
activities that are not permitted include (1) sending or displaying offensive messages, pictures or materials; (2) using obscene language,
harassing, insulting or attacking others; (3) damaging electronic components, computers, computer systems, or networks, including knowingly
transferring viruses; (4) violating copyright laws or using others’ passwords; (5) trespassing in others’ files, folders or storage areas of any
kind; (6) intentionally wasting limited resources; (7) using the network for commercial, political or any unlawful purposes; and (8) installing
any personal software on college equipment.
Sexual Harassment: All employees and students are guaranteed the right to work and learn in an environment free from sexual harassment.
This behavior is considered a form of discrimination based on sex, and as such is prohibited by Title IX of the Educational Amendments of
1972, which prohibits sex discrimination against students and employees in educational institutions receiving federal funds.
Prohibition of Weapons on Campus: No person, whether student, employee, or visitor, may possess or carry, whether openly or concealed,
any weapon on any campus or other educational property of Surry Community College.
Unlawful Demonstrations, Violence, or Force: Recognizing the right of dissent, criticism, and protest, it is the policy of the college to give
full and prompt attention to such expression presented in a lawful manner. However, the use of unlawful violence, disturbances,
demonstrations, force, the occupying or damaging or property or intimidation will not be tolerated.
Campus Security: The SCC Campus Security Report is available on the college website (www.surry.edu). This report provides statistics
on past occurrences of crimes committed on college property, information about crime prevention, crime reporting, and policies concerning
campus security. If you would like a paper copy of this report, you may obtain one in the Student Development Office.
Graduation Rates: Title II, Public Law 101-542, dated November 8, 1990, requires educational institutions to disclose graduation rate data.
Such data for Surry Community College are available in the Office of Planning and Institutional Research, Richards Health Sciences Building,
room H-218.
Voter Registration: Voter Registration Application/Update forms are available in the Student Development Office.
Release of Students' Pictures: SCC uses pictures and videos of college activities and students for public information and advertising
purposes. Students who do not want to appear in such photographs or videos should notify the Office of Student Services and Surry
Community College Marketing Department in writing.
Surry Community College provides educational and employment opportunities without regard to race, religion, national origin, age, gender, or disability.
For additional information, contact the Office of the Vice President for Academic and Student Affairs.