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Health & Wellness - Nurse Aide/Med Aide/Med Tech
Select CORRECT Class*  
Nurse Aide I, $244
Nurse Aide II, $219
CNA Refresher, $125
Med Aide, $70 (NC CNA certification required)
Med Tech, $95

STOP: If you cannot submit payment or apply for a scholarship (if applicable), within 3 - 4 business days (or by the provided payment deadline), please DO NOT submit your registration form. You will be dropped for non-payment.

Class Start Date:*  
Class End Date:*  
Section Number (refer to schedule on website)*  
Class Location*  
E-Mail
Important: Enter a valid e-mail address. Be sure to check your email for correspondence and course instructions. If you have not received a response, check your spam/junk folder or contact Nancy Watts.
E-Mail:*  
Registrant Information: Please use your LEGAL name as it appears on your government issued ID.
First Name:*  
Middle Initial:  
Last Name:*  
Address Line 1:*  
Address Line 2:  
City:*  
State:*  
County (NC residents only)  
Zip Code:*  
Home Phone:*  
Cell Phone:*  
Sex*  
Male Female 

Date of Birth*  
  
  
SSN*  
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/Race Origin:*  
Educational Experience
Highest Educational Level Completed.*  
Do you have a valid NC CNA Certification? This is required for those applying for Med Aide or NA II.*  
Yes No 

Please provide how your name appears on your valid NC CNA certification:*  
Employment Status
Employment Status*  
Electronic Signature & Payment Information
I understand that having any unpaid balances wtih Piedmont Community College may affect my enrollment in this class.
*ATTENTION: DO NOT SUBMIT UNLESS YOU CAN COMPLETE PAYMENT by the deadline. Payment or scholarship application (if applicable, details will be sent in payment email) must be received by the set deadline. You will receive a detailed email from Nancy Watts (please allow 5 Business days for registration to take place!) with payment instructions and the given deadline. Students who have not submitted payment by the deadline, will be dropped and have to re-register for the course. If you have not received your payment instructions via email AFTER 5 business days, please contact Nancy Watts.
Signature:*  
Enter first & last name
Date*  
Amount Due:*  
Enter registration fee
Photography & Quote Release: I hereby authorize Piedmont Community College to use my image and/or quotes for any use the College deems appropriate in the promotion and marketing of PCC. I fully discharge PCC from any and all claims, monetary or otherwise, arising out of the image or quote.
Signature:  
Optional, sign if authorized
Date:  
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