Registration Instructions: Fill in the blanks below. Those marked with an * are mandatory. When complete, click on the submit button. If you have any problems registering, please call the Training Coordinator at (252) 738-3345 BUSINESS/OFFICE ONLY Course Title * Last 4 digits of SSN * Collection of Social Security Numbers: Vance-Granville Community College is legally authorized to collect student Social Security numbers in order to comply with certain federal and state reporting requirements, and to meet the business imperatives of the college. * Last Name * Maiden Name First Name * Middle Name ADDRESS Mailing Address * City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * NC Resident * No Yes County of Residence * TELEPHONE NO Home No * Cell No BIRTHDATE/AGE Date of Birth * Age * Under 18 * No Yes If you are under 18, there will be additional forms required. DEMOGRAPHICS Race/Ethnic Background White Black Asian American Indian Hispanic Gender Male Female Employment Full-Time Part-Time Retired Unemployed Employer EDUCATION Highest Grade Completed - None -1 Grade2 Grade3 Grade4 Grade5 Grade6 Grade7 Grade8 Grade9 Grade10 Grade11 Grade12 GradeGEDAdult HS DiplomaVocational DiplomaAssociate DegreeBachelor's DegreeMaster's Degree Higher Email Address * COURSE INFORMATION Course Title Class Time Section ID Length/Hrs. Fee Starting Date Ending Date Location Course URL (1) Refund Policy: Students will be eligible for a 100-percent refund if official withdrawal occurs prior to the first class meeting or the class is cancelled. After the course begins, a 75-percent refund can be made if the student officially withdraws prior to or on the 10-percent point of the scheduled hours. For contact-hour classes, five calendar days from the first day of class is the determination date. For self-supporting classes, no refund will be made unless the class is cancelled. (2) Repeat Policy: Students who take an Occupational Extension course more than twice within a five-year period shall pay their cost for the course based on the amount of funds generated by a student membership hour for Occupational Extension multiplied by the number of actual hours the class is to be taught. Students may repeat Occupational Extension courses if the repetitions are required for certification, licensure, or recertification. (3) Grading Policy: In order to receive a satisfactory (S) grade, students must be present for at least 80-percent of the class hours scheduled. Students signature on this form gives permission for VGCC to release his/her grade to the appropriate certification agency, employer or prospective employer, when applicable. Grade Release Gives permissions Payment Type - None -Online through VGCC Market Place(Visa or Mastercard)Cash/Check(In-person)Company/Agency to be billed (written authorization required) Company or Agency to be billed (address required) Form Verification Yes No By Choosing "Yes", I certify to the best of my knowledge that the information given is true and complete. Further, I understand that by submitting this information via electronic transmission that I acknowledge the above statement of certification in lieu of a signature. Initials * EMS/FIRE RESCUE STUDENTS ONLY Fee Waiver - None - (CEVFR) Volunteer Fireman (CEPFR) Paid Fireman (CEPLW) Paid Law Enforcement (CEVRS) Volunteer Rescue Squad (CEPRS) Paid Rescue Squad Other Fee Waivers Agency/Job Title (Required) For Adult Defensive Driving/Alive @25 students please call with additional information for the class registration to be completed. We will need your Driver License # and the reason for the ticket and the court date. Adult Defensive Driving 252-738-3345 and Alive@25 252-738-3324.