STUDENT REGISTRATION FORM
R-CCC STAFF ONLY
Workforce & Continuing Education Division
P.O. 1248 - Ahoskie, NC 27910
Phone: (252) 862-1200 - ConEd Department: (252) 862-1202 - Public Safety Department: (252) 862-1266
www.roanokechowan.edu/continuing-education
Entered By ____________________
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ID Copied
Grad Verified
Registered
TO ENROLL IN CONTINUING EDUCATION COURSES, YOU MUST BE 18 YEARS OF AGE OR OLDER. If you are under age 18, then you must have a Minor Release Form signed by your High School Principal or his/her designated representative in order to be eligible to enroll in Continuing Education courses. (This form may be obtained from our office. All students must provide a copy of their valid ID (Driver's License, ID, etc.) and proof of high school graduation if applicable.
Instructions: Type or print legibly in ink. Respond to all questions completely. Return completed form and required documents to the Registrar's Office.
Name
First Name
Middle Initial
Last Name
Course Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
County of Residence
State of Residence
Country
U.S. Citizen:
Yes
No
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Social Security Number
Date of Birth:
-
Month
-
Day
Year
Date
Gender:
Male
Female
Ethnicity:
Hispanic/Latino
Not Hispanic/Latino
Race:
Asian
Black or African American
White
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
How did you hear about this course? Please check only one.
Advertisement
Corporate Contact
Personal Initiative
Recruitment Activities
Referral
Other
Check one of the following graduation types:
High School Graduate
High School Equivalency Completion
Current Dual Enrollment/CCP Student
Did not graduate High School
Adult High School Graduate
Name of High School attended or High School Equivalency received from:
Year Received:
Student Type:
Not applicable
Fire & Rescue/EMS/Law Enforcement
Dual Enrollment/CCP
Employee
Senior Citizen
Inmate
Employment Status: Please check one.
Retired
Employed 1-10 hours per week
Employed 40 or more hours per week
Unemployed-Not Seeking Employment
Employed 11-20 hours per week
Unemployed-Seeking Employment
Employed 21-39 hours per week
Employer
Address
Highest educational level completed: Please check one.
1
2
3
4
5
6
High School Equivalency
One Year Vocational Diploma
Bachelor's Degree
7
8
9
10
11
12
Adult High School Diploma
Associate Degree
Master's Degree or Higher
Is your tuition being paid by an agency/organization? If yes, please specify
(Copy of authorization to pay must be on file or attached)
Are you taking this course for certification?
Yes
No
Please complete the following if it applies to you: I hereby give permission to Roanoke-Chowan Community College and the NC Community College System to release my grades to:
NC Department of Insurance Fire/Rescue Commission
Employer
Other
NC Criminal Justice's Training & Standards Commission and/or NC Sheriff's Commission
NC Criminal Justice's Training & Standards Commission and/or NC Sheriff's Commission
Potential Employer
By signing, I certify that I am 18 years old or older or have included a Minor Release Form and that the above information is correct.
Signature
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*Programs at R-CCC that prepare students for professional licensure(s)/certification(s) are designed to prepare a student to apply for applicable licensure/certification in North Carolina. In order to ensure whether the program meets requirements for professional licensure(s)/certification(s) outside North Carolina, R-CCC recommends the student contact the Dean of Workforce & Continuing Education or Program Coordinator prior to enrolling in the course.
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