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Last Name: ______________________ First Name: _______________ Middle: _______________Birthdate:___________
Street Address: _______________________________________________________ City: __________________________
State: ___________ Zip: _________ Primary Phone#:________________________ AltPhone#_____________________
SS#: __________________ GC ID#:_____________Email: __________________________ ☐ Male ☐Female
How did you hear about this
The following information is used for federal and/or state reporting purposes and to help provide
support for our programs. Your answers are completely voluntary and will be kept strictly
confidential. Please make one selection from each section.
Are you?
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Hispanic/Latino
☐ Asian
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Non-Hispanic/Latino
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Decline to Answer
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Hawaiian/Pacific Islander
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☐CASH ☐CHECK ☐AGENCY ☐EMPLOYER ☐GRANT ☐MASTERCARD ☐VISA
☐AMEX ☐DISCOVER
CARD NUMBER: __________________________________________ EXPIRATION: _________________ V-CODE: ____________
You have my permission to use photos in which I appear for GC publicity
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NO
Updated 08/2019
REGISTRATION FORM- PLEASE PRINT LEGIBILY
Course Name Course Number Start Date Cost
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Is this registration pending TPEG Award? ☐ Yes ☐ No
Total Cost ________________
The
information I have provided is complete and correct to the best of my knowledge. I agree to abide by the policies, rules and
regulations in the
programs to which I am admitted. I authorize the college to verify the information I have provided. I further
understand that the information submitted
herein will be relied upon. I understand that by registering for the courses listed above that I am responsible for the payment of the courses listed.
Refunds will only be given if you notify the CE office prior to the course starting date. No Refunds will be given after the course has started and a hold will
be placed on your account for any balances owed.
Galveston College has established policies and procedures to comply with the “Family Educational Rights and Privacy Act of 1974” and the “Texas Open Records Law” FERPA (State Senate Bill 1071
and House Bill 6). This information is available via our catalog and website. FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions
(34 CFR § 99.31): School officials with legitimate educational interest (Galveston College considers personnel instructing/supervising students at clinical, internship, and other practicum sites as school
officials); Other schools to which a student is transferring; Specified officials for audit or evaluation purposes; Appropriate parties in connection with financial aid to a student; Organizations conducting
studies on certain students for or on behalf of the school; Accrediting organizations; To comply with a judicial order or lawfully issued subpoena; Appropriate officials in cases of health and safety
emergencies; and,Federal,State and local authorities, within a juvenile justice system, pursuant to specific state law.
Applicants Signature: ____________________________________________ Date: _________________
Signature of Parent (if minor): ______________________________________ Date: _________________
It is the policy of Galveston College to provide equal opportunities without regard to age, race, color, religion, national origin, sex, disability, genetic information, or veteran status
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