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College & Career Readiness High School Equivalency Prep Classes
COURSE INFORMATION
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Registrant Information
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County (NC Residents Only)

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Home Phone*

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Disclaimer
Students must be at least 16 years old to take these courses through PCC. No exceptions. This is an NC law. If you are 16 or 17 years old, please contact our office for an additional form that your parents must complete.

Birth Month*

Day of Birth*

Year of Birth*

Social Security Number*


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 and ethnic backgrounds of our students and employees. To respond to these requests, we ask you to answer the following two questions:
Sex/Gender
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Do you consider yourself to be Hispanic/Latino?
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Ethnic Origin

Education and Employment
Highest Education Level Completed*

Employment Status*

Electronic Signature
The information I have given is accurate to the best of my knowledge. I understand that having any unpaid balances with Piedmont Community College may affect my enrollment in this class.
Digital Signature*

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