Johnston Community College - Con. Ed. Registration Form

JOHNSTON COMMUNITY COLLEGE

Continuing Education Student Registration Form

Mail or deliver completed form and appropriate registration fee to:

Johnston Community College
Continuing Education Division
PO Box 2350, Smithfield, NC 27577
Telephone # (919) 934-3051

Print out and complete the application in full and return to the address listed above. Please print in ink or type.

Course Title________________________________________________________Registration Fee ___________

Semester ___________ Location ________________________________Beginning Date___________________

Social Security Number __ __ __ - __ __ - __ __ __ __ Date of Birth __________________ Sex ( ) Male ( ) Female

Name______________________________________________________________________________________
                     Last                                                           First                                                                        Middle

Address (Street, PO Box, Route)____________________________________________________________________

(City, State, Zip)______________________________________________ County of Residence ________________

Telephone Number (Home) ___________________________ (Business) _________________________________

Circle Highest Grade Completed:   0   1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17
       or check ( ) if passed high school equivalency

Employment Status: ( ) Retired   ( ) Unemployed   ( ) Part Time   ( ) Full-Time

Employer _________________________________________________Occupation ________________________

Please read the following policies concerning your registration.

Continuing Education Refund Policy: A student who officially withdraws from a Continuing Education course prior to the first class meeting is eligible for a 100% refund upon request to the Continuing Education Division. Upon official withdrawal from a Continuing Education Course, a student may be entitled to receive a 75% refund of the registration fee in certain circumstances. The Continuing Education refund policy applies to courses offered as Occupational Extension and Community Services. Courses offered as self-supporting are not eligible as these programs are funded by registration fees collected. In order to qualify for a refund, a student must officially withdraw and request a refund (in writing) prior to or on the 10% date of the course. Requests for refunds after the 10 % point will not be considered. Students are eligible for a 100 % refund if the class is canceled by the College.

Course Repetition Policy: A special provision of the State General assembly concerning course repetition became effective July 1, 1993. Students who take an occupational extension course more than TWICE within a FIVE-YEAR period shall pay their cost for the course at a rate based on current contact hour value. Students shall be primarily responsible for monitoring course repetitions, however, the College shall review records and charge students full cost for courses taken more than twice. Senior citizens who are legal residents of North Carolina may enroll in the same occupational extension course free of charge TWICE within a FIVE-YEAR period. Senior citizens who take an occupational extension course more than TWICE within a FIVE-YEAR period shall pay their cost for the course at a rate based on current contact hour value. Students may repeat occupational extension courses an unlimited number of times, if the repetitions are for certification, licensing, or recertification.

The above information is accurate to the best of my knowledge and I have read the Continuing Education Refund Policy and the Course Repetition Policy and understand how each applies to my registration for this course.

Student Signature ________________________________________________Date _______________________

Method of Payment: ( ) Cash   ( ) Check # _____________ or Money Order enclosed (payable to JCC)

( ) Credit Card Indicate : ____ Master Card ____VISA

Account Number____________________________________ Expiration Date __________

Authorized Signature ________________________________________Date ___________

For JCC Office Use: Contract Number: _________________________ Date Received:_________________
                                      Program Code _______________ AR Code ___________ Received By: ______________________

Course Title________________________________________________________Registration Fee ___________
Semester ___________ Location ________________________________Beginning Date___________________
Social Security Number __ __ __ - __ __ - __ __ __ __ Date of Birth __________________ Sex ( ) Male ( ) Female
Name______________________________________________________________________________________ Last First Middle
Address (Street, PO Box, Route)____________________________________________________________________
(City, State, Zip)______________________________________________ County of Residence ________________
Telephone Number (Home) ___________________________ (Business) _________________________________
Circle Highest Grade Completed: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 or check ( ) if passed high school equivalency
Employment Status: ( ) Retired ( ) Unemployed ( ) Part Time ( ) Full-Time
Employer _________________________________________________Occupation ________________________
*Please read the following policies concerning your registration.*
Continuing Education Refund Policy: A student who officially withdraws from a Continuing Education course prior to the first class meeting is eligible for a 100% refund upon request to the Continuing Education Division. Upon official withdrawal from a Continuing Education Course, a student may be entitled to receive a 75% refund of the registration fee in certain circumstances. The Continuing Education refund policy applies to courses offered as Occupational Extension and Community Services. Courses offered as self-supporting are not eligible as these programs are funded by registration fees collected. In order to qualify for a refund, a student must officially withdraw and request a refund (in writing) prior to or on the 10% date of the course. Requests for refunds after the 10 % point will not be considered. Students are eligible for a 100 % refund if the class is canceled by the College. Course Repetition Policy: A special provision of the State General assembly concerning course repetition became effective July 1, 1993. Students who take an occupational extension course more than TWICE within a FIVE-YEAR period shall pay their cost for the course at a rate based on current contact hour value. Students shall be primarily responsible for monitoring course repetitions, however, the College shall review records and charge students full cost for courses taken more than twice. Senior citizens who are legal residents of North Carolina may enroll in the same occupational extension course free of charge TWICE within a FIVE-YEAR period. Senior citizens who take an occupational extension course more than TWICE within a FIVE-YEAR period shall pay their cost for the course at a rate based on current contact hour value. Students may repeat occupational extension courses an unlimited number of times, if the repetitions are for certification, licensing, or recertification. The above information is accurate to the best of my knowledge and I have read the Continuing Education Refund Policy and the Course Repetition Policy and understand how each applies to my registration for this course.
Student Signature ________________________________________________Date _______________________
Method of Payment:	( ) Cash ( ) Check # _____________ or Money Order enclosed (payable to JCC)
	( ) Credit Card Indicate : ____ Master Card ____VISA
	Account Number____________________________________ Expiration Date __________
	Authorized Signature ________________________________________Date ___________