CE Human Resources Development Registration Form

Course Title*

Full Name*

First Middle Last

Address*

Mailing Address City State ZIP Code

County*

Phone*

Alternate Phone

Email*

Date of Birth*

Race*

American/Alaska Native
Asian
Black or African American
Hawaiian/Pacific Islander
White
Other

Ethnicity*

Hispanic/Latino
Non-Hispanic/Latino

Gender*

Employment Status*

Highest Level of Education*

The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in classes coded in the Master Course List as Human Resource Development, if the individual meets one of the four criteria listed below. To receive this waiver, an individual must verify that he or she meets at least one of the criteria by completing and signing this form. Individuals not signing this form must pay the applicable fee to register for Continuing Education.

I qualify for a tuition and fee waiver under the following criteria:*

I am currently unemployed.
I have received notification of a pending layoff.
I am working and eligible for the Federal Earned Income Tax Credit.
I am working and earn wages at or below two hundred percent (200%) of the federal poverty guidelines.

Must meet at least one of the four criteria listed.

I hereby verify that all the information given by me as presented above is complete and accurate to the best of my knowledge by my electronic signature below.*

Type your full name as your electronic signature.

Date*

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CE Human Resources Development Registration Form

Continuing Education Human Resources Development (HRD) Registration Form