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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 scholarship or NCWorks sponsorship.

If you do not qualify for financial assistance or plan to pay out of pocket, do not use this form. Return to the Self-Service Portal to complete registration and payment.
Select Intended Sponsorship*  
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*  
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.*  
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 2 business days 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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