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Continuing Education Registration Form
Course Information
*Course title(s)One form for multiple classes.
Month the first course begins
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 
E-Mail
Important: Enter a valid e-mail address. Correspondence will be sent to this address.
*E-Mail:
Registrant Information
*First Name:
Middle Initial:
*Last Name:
*Address Line 1:
Address Line 2:
*City:
*State:
County (NC residents only)
*Zip Code:
*Home Phone:
Work Phone:
Cell Phone:
*Are you a returning student? Please state Yes or No.*
Students must be at least 16 years old to take these courses through PCC. No exceptions. This is a NC law.
If you are 16 or 17 years old, please contact our office for an additional form that your parents must complete.
*Date of Birth:
Social Security Number
*Sex
Male Female 
Colleges and Universities are asked by many, including the federal government, accrediting associations, college guides, newspapers, and your own college/university communities, to describe the racial ethnic backgrounds of our students and employees. In order to respond to these requests, we ask you to answer the following two questions:
Do you consider yourself to be Hispanic/Latino?
Yes No 
Ethnic Origin:
I understand that having any unpaid balances with Piedmont Community College may affect my enrollment in this class.
Educational Experience
*Highest Educational Level Completed
10 11 12 High School Graduate GED (General Educational Diploma) Vocational Diploma/Certificate Associate Degree Bachelor`s Degree Master`s Degree or higher 
Employment Status
*Employment Status:
Electronic Signature
The information I have given is accurate to the best of my knowledge.
*Signature:
*Date
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