Continuing Education Non-Credit Registration Form

The college is required to have your correct SSN per IRS Code, Section 6109.

Personal Information:

* SSN/Student ID: Required

* Last Name: Required

* First Name: Required

M.I.:

*Mailing Address: Required

City Required

State Required

Zip Code Required

Home Phone: Required

* Work Phone: Required

* Date of Birth: Required

* Email Address: Required You must enter a valid email address

Gender:

Female

Male

How did you hear about us?

ETHNIC ORIGIN (Required by the Federal Government)

Are you Hispanic?

Yes

RACE: Choose one or more (for Non_Hispanics)

By entering my name in the space below, I understand that GCSC will provide my student information to the appropriate agencies for fee payment if I am not paying for this course and/or for licensure/CEU purposes, if required.

* Student Signature: Required

Date:

State Regulated Professional License Number:

*CRN# Required

COURSE #

*COURSE TITLE Required

DATE

TIME

FEE

Refund Information: sts must be received by 12:00 pm five workdays before the first day of the class (excluding paid online classes). Please send a refund request email to the program coordinator for the course for which you are enrolled. All refunds are issued by check to the person assigned to the student ID listed on the registration. Online classes and hybrid classes are non-refundable once access has been granted.

If you need to copy of this registration form, please print from you browser menu prior to hitting submit.

You will receive an e-mail notification when your registration has been received with payment instructions. Your class registration will not be complete until the course has been paid. Thank you.