College & Career Readiness GED® & HiSET® Prep Classes

Course Information
Course Title*
Course Title*
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*		1 2 3 4 5 6 7 8 9 10 11
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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