Community Training & Development
Non-Credit Registration Form www.ccac.edu/workforce
Please print. Complete and return this form with payment (if applicable). No further notice will be provided.
Date of Birth ( required for enrollment ) MM/DD/YYYY:
Last Name:
First Name:
Middle Initial:
Street Address:
Apt:
City:
State:
Zip:
County:
Alternate Phone:
Home Phone:
New Address (X):
Email Address:
Have you ever served in the Military (circle one)? No – Yes (see below) Are you a dependent of a Veteran (circle one)? No – Yes (see below)
NOTE: If YES to either question, please contact the CCAC Veterans Services Office at 412.237.6503.
Veteran Benefits:
This voluntary information is compiled by the college for statistical purposes only and no personally identifiable information will be released. Marital Status: Do you consider yourself to be Hispanic/Latino/Spanish Origin? □ Single □ Married □ Yes □ No □ Divorced □ Separated In addition, select one or more of the following racial categories □ Widowed to describe yourself: Sex: □ American Indian/Alaskan □ Asian □ Male □ Female □ Black or African American □ White or Caucasian □ Native Hawaiian or Pacific Islander
Veteran not using benefits
35 Dependent
Chapter 33 Post 9/11 Gi Bill
Place of Permanent Address (check one) □ Allegheny County (1)
□ Out -of-State (5) □ Out -of County
Payment Must Be Enclosed (if applicable) Print Phone Number on Check or Money Order (Checks Payable to CCAC). Mail To: CCAC ~ CHRISTINE MAJEWSKI
Because CCAC cares about your privacy, we cannot process credit card information by mail. Please visit ccac.edu , any CCAC facility; or call 412-788-7546 to register if you prefer to pay by credit card. REFUND POLICY: Students not attending the program (course) must notify CCAC in person, by mail or at 412-369-3701 BEFORE the first day in order to receive a refund. CCAC will notify registered students in the event that the program (course) is cancelled.
BYERS HALL ~ 203 808 RIDGE AVENUE PITTSBURGH PA 15212
Cost (if applicable)
Course Number
Semester
Course Title
Course Location
Student Signature (Required for enrollment)
Date
If sponsored, Authorizing Agency
& Signature
Date
If you require special arrangements, contact the nearest CCAC Supportive Services office prior to class: Allegheny – 412.237.4612 • Boyce – 724.325.6604 North – 412.369.3686 • South – 412.469.6207 TTY – 412.369.4110 & 412.469.6005
I agree that once I register, I become legally bound by and agree to the terms of Community College of Allegheny County Student Financial Responsibility Agreement and as such become responsible for all charges incurred, unless I drop classes during the designated refund period.
The college is subject to provisions and complies with the Family Educational Rights and Privacy Act of 1974. A statement of the college policy can be found in the student handbook and college catalog. Voluntary information used to comply with Federal reporting and has no effect on admission to the college. The college is subject to provisions of and complies with the Family Educational Rights & Privacy Act of 1974. A statement of the college policy can be found in the student handbook and college catalog. Form Updated 2017
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