Fillable REGISTRATION FORM Ive taken classes at WITC in (Wisconsin Indianhead Technical College)

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REGISTRATION FORM Ive taken classes at WITC in (Wisconsin Indianhead Technical College)

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Country of origin: US
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U.S.A. forms for Wisconsin Indianhead Technical College

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_________________________________________________________________________________________________________________
REGISTRATION FORM
for Continuing Education (non-credit) Courses
WITC is an equal opportunity employer/educator.
CLASS NO. CATALOG NO. CLASS TITLE LOCATION START DATE CLASS FEE
OFFICE USE ONLY
TOTAL
Term:
______
38.14 Contract #
_______________
Employer #
__________________
Course Fees
$__________________
Senior Fee
$
______________ _______________
Date/Time _______________________
Received By/Ext.
PAYMENT METHOD: Check or money order payable to WITC Cash MasterCard Visa Discover Exp. Date __________________ Security Code _________________
Agency Bill/Sponsored Registration - complete information below; attach required authorization
Month / Year
3.17
I’ve taken classes at WITC in the past.
___________________________________________________________________________
Email address (required for WITC alerts and important communication)
___________________________________________________________________________
Home phone Cell phone
___________________________________________________________________________
Home address
City State ZIP
__________________________________________________________________________BBB_
Resident of (check one):
Township
Village
City County School District where you live Last high school attended
The information below is required for state and federal reporting purposes, and will be kept confidential.
Female
Ethnicity: Hispanic/Latino origin?
Yes
No
Race (check all that apply):
American Indian/Alaska Native
Asian
Black/African American
White
Highest Credential Earned
01 = No Credential
02 = GED
03 = HSED
04 = High School Diploma
05 = Some college credit
07 = 1yr Diploma
08 = 2yr Diploma
09 = Associate Degree
10 = Associate Degree
Plus Additional Credential
11 = Baccalaureate
12 = More than Baccalaureate
99 = Student Declined/Unknown
Last Name First Name M.I. Former Last Name (if applicable) Date of Birth Age 62+?
Native Hawaiian/Other Pacific Islander
06 = Short-term diploma or certificate
It is your responsibility to contact WITC to officially drop a class. If you decide to drop, you should do so immediately
as a single day can affect your refund amount. A full refund will be given if you notify WITC prior to the first scheduled class meeting.
Male
Gender:
Once registered for a course(s), you have created a liability with WITC and a promise to pay.
_________________________________________________________________________________________________________________
_________________________________________________________________________
No student ID, or don't remember?
Provide Social Security No.
WITC Student ID No.
___________________________________________________________________________
_______________
Youth Registration: With parent/guardian permission, students age 16 or younger can attend WITC courses scheduled outside student’s normal school hours.*
*Some courses may have minimum age prerequisites.
Signature of Parent/Legal Guardian Date
BBBBBBBCOMPLETED (K-12): ________
Trac-Related Registration: Motorcycle, Traffic Safety, Group Dynamics, Multiple Offender
Driver’s License Number
Sponsored Registration: If an agency or employer has agreed to pay your tuition, complete the section below and attach written authorization.
Name of Business/Agency EMS/Fire Sponsor
I authorize WITC to forward information regarding the completion of this course to the sponsor listed above.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Student Signature
___________________________________________________________________________
___________________________________________________________________________
Assessment Agency and Date
Credit Card No. Name on Card Cardholder Signature
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Other
_______________ _______________
$ 0.00
Highest grade
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REGISTRATION FORM Ive taken classes at WITC in (Wisconsin Indianhead Technical College)

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Completed 11 October 2020

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