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ADULT EDUCATION & TRANSITION PROGRAM REGISTRATION
High School Equivalency & Adult High School Diploma
English as a Second Language (ESL)
 
COURSE SELECTION
 
Program of Interest*

Career and Tutoring Services

 
STUDENT INFORMATION
 
First Name*

Last Name*

Middle Initial

E-Mail Address*

 
Mailing Address*

City*

State*

ZIP Code*

County (NC Only)*

 
Home Phone*

Cell Phone

SSN/ITIN*

Birth Month*

Birth Day*

Birth Year*

 
Last Grade Completed*

Employment Status*

Ethnicity*

Race*

 
Are you a Returning Student?*

Gender*

DISCLAIMER
Age Requirement Notice

By North Carolina law, students must be at least 16 years of age to enroll in courses offered through Piedmont Community College. No exceptions are permitted. Students who are 16 or 17 years old must contact our office to obtain and submit an additional form requiring a parent or legal guardian`s signature.

Disclosure of Demographic Information

Piedmont Community College is often asked to provide general statistics about the racial and ethnic makeup of our student body and employees. Your response will not affect your admission or enrollment. All information collected is protected personal information and is not shared externally without explicit permission. PCC abides by strict FERPA Laws.      
ELECTRONIC SIGNATURE
 
SIGNATURE*

 
DATE*

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