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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
course or program?
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?
☐
Printed Schedule
☐
Social Media
☐
Hispanic/Latino
☐ Asian
☐
GC website
☐
Flyer
☐
Non-Hispanic/Latino
☐
Black/ African American
☐
Agency Referral
☐
Newspaper
☐
Decline to Answer
☐
Hawaiian/Pacific Islander
☐
Friend/Relative
☐
Other
☐
Native American/Alaskan
☐
White/Caucasian
☐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
☐ YES ☐
NO
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
Upd
ated 7/18
REGISTRATION FORM- PLEASE PRINT LEGIBILY
COURSE SELECTION
Course Name Course Number Start Date Cost
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Is this registration pending TPEG Award? ☐ Yes ☐ No
Total Cost ________________
PAYMENT INFORMATION
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.
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.
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Completed 27 July 2020

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