Continuing Education Application

Continuing Education Application

601 Martin Luther King, Jr. Avenue, Kingstree, SC 29556-4103

843-355-4116 or 4177 www.wiltech.edu
Last*
First*
Middle I. or Maiden
Suffix
Street Name/Number/PO Box*
City*
State*
Zip*
County of Legal Residence*
Permanent/Home Phone*
Cell Phone
E mail address
example@example.com
SSN Number*
Birthdate*

MonthDayYear
Date
Ethnic Identification (Choose One)*

Hispanic/Latino If you did not select Hispanic/Latino, please select one of the following:American Indian/Alaska NativeBlack/African AmericanWhiteAsianTwo or more racesNative Hawaiian/Pacific Islander
Gender*

MaleFemale
What is your Program of Interest?*
Declaration of Citizenship or Legal Presence in the United States: The South Carolina Illegal Immigration Reform Act (SC Code Ann. $59-101-430) prohibits those unlawfully present in the United states from attending Williamsburg Technical College or any other public institution of higher education in South Carolina and from receiving a public higher education benefit. By signing below, you attest that you are a US citizen, a legal permanent resident in the United States, or an alien lawfully present in the United States. In addition, Williamsburg Technical College may require that you submit documentation that supports your claim. Any student providing false-information may be subject to dismissal from the college. Any student who is found to be unlawfully present in the United States will be dismissed from the college.
Print Name*
Today's Date*

MonthDayYear
Date
Signature*

Clear
SCDL or ID#*
Statement of Terms and Non-discriminatory Policy: Continuing Education courses may be cancelled if insufficient enrollment warrants. If a Continuing Education course is cancelled by the college, course fees will be refunded in full. If the course is taught and one decides to drop, withdraw, or not attend, normally no refund is given. Students under the age of 16 years may take continuing Education courses with the written permission of the parent/guardian. Some courses are not available to minors due to SC laws and/or discretion of the instructor. Senior citizens pay the same advertised course fee as all others. The language in this docu- ment does not create an employment contract between the employee and agency. This document does not create any contractual rights or entitlements. The agency reserves the right to revise the contents of this document, in whole or in part. No promises or assurances, whether written or oral, which are contrary to or inconsistent with the terms of this statement create any contract of employment.

Williamsburg Technical College does not discriminate in its admissions practices, educational programs, activities or employment on the basis of sex, age, disability, race, color, national origin, or religion.
Course
Bill to
Start date

MonthDayYear
Date
End Date

MonthDayYear
Date
Class time
Room
Instructor
Fee
Received by
Date

MonthDayYear
Date
Should be Empty: