Continuing Education Course Registration Form
PO Box 1248
*
A
h
o
s
k
ie,
NC
2791
0
*
ww
w
.
ro
a
n
o
k
e
c
h
o
w
a
n
.e
d
u
Course Title
*
Section Number/Term
Social Security # or Colleague ID#
*
Date of Birth (M/D/Y)
*
/
Month
/
Day
Year
Date
Name
*
(please print & no nicknames)
Last Name
Mailing Address
*
City
*
State
*
Zip
*
State (Physical Residency)
*
County (Physical Residency)
*
Email Address
*
Home Phone ( )
Cell Phone ( )
*
Ethnicity
*
Hispanic/Latino
Non-Hispanic/Latino
Gender
*
Male
Female
Race
*
White
Black/African American
American Indian/Alaska native
Asian
Hawaiian/Pacific Islander
Other(specify)
Highest Level of Education Completed
*
10th or less
11th
12th/High School Diploma
GED/Equivalency
One Year Vocational Diploma
Associate Degree
Bachelor's Degree
Master's Degree or Higher
Employment Status
*
Retired
Full-Time
Part-Time
Unemployed - Not Seeking
Unemployed - Seeking
Employer
*
Job Title
*
Fee Waiver, if appropriate/Check all or any that apply
*
Paid Firefighter
Volunteer EMS
Law
Human Resources Dev.
Volunteer Firefighter
Paid EMS
Inmate
Not Applicable
If fee waived list agency affiliation
*
Job Title
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
R
C
C
C
40
2
Oct
.
’2
1
P
r
e
v
i
ou
s
e
d
itio
n
s
ob
s
o
lete
Continue
Continue
Should be Empty: