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Health & Wellness
Select CORRECT Class*  
Cardio Tech/EKG, $234
Central Sterile Proc., $194
Pharmacy Tech, $185
Phlebotomy, $472

🚨 STOP — READ CAREFULLY 🚨

This form is ONLY for students applying for financial assistance. You must select the form of assistance you intend to use below - THIS IS NOT THE SCHOLARSHIP APPLICATION! If you submit this form, you will receive a payment instruction email within 24 business hours. Please follow the instructions provided in that email to secure your seat by the deadline.

❗ Do NOT use this form if you plan to pay out of pocket or do not qualify for financial assistance. Instead, return to the Self-Service Portal to complete your registration and payment.
Select Intended Form of Payment*  
Important: Submitting this form does NOT secure your seat and is NOT a scholarship application. After staff place you in the course, you will receive a payment instructions email within 24 business hours. You must follow those instructions to complete your registration.
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 Lori Watlington.
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*  
Do you consider yourself to be Hispanic/Latino?*  
Yes No 

Ethnic/Race Origin:*  
Educational Experience
Highest Educational Level Completed.*  
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: You will receive an email from Lori Watlington within 24 business hours with scholarship instructions. You must submit your scholarship form or NCWorks contact info by the stated deadline. Missing the deadline will result in being dropped and required to re-register. If you do not receive the email after 2 business days, contact Lori Watlington.

Signature:*  
Enter first & last name
Date*  
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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