Montgomery Community College :: WDC Form

WDC Form

WDC Registration

Full Legal Name*

First and last name
Date*
MM slash DD slash YYYY
Social Security Number
Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
Race*
- White
- Black
- Hispanic
- Indian
- Asian
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Home Phone
Cell Phone*
Highest Education Completed*
Last High School Attended*
Last High School State*

Please include what state the last high school attended is located
Last High School Year*

Please include the year graduated or the last year you attended
Employment*
- Full-Time
- Part-Time
- Unemployed-Seeking
- Unemployed-Not Seeking
- Retired
Complete if an active volunteer or paid member of EMS, DOC, DPS, Law Enforcement, or Fire Department:
Agency Affiliation*
Job Title*
My signature attests that I am actively affiliated with the public safety agency listed and I hold the job classification indicated. Furthermore, I agree to allow my employer to access my academic record.
Class Info*
Class Title Start Date
HRD Tuition and Fee Waiver – Verification Statement
The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in classes coded as Human Resources Development if the individual meets one of four criteria listed below. Individuals not signing this form must pay the applicable fee to register for a Continuing Education course.
I qualify for a tuition and fee waiver under the following criteria:*
- I am currently unemployed
- I have received notification of a pending layoff
- I am working and eligible for the Federal Earned Income Tax Credit
- I am working and earning wages at or below two hundred percent (200%) of the federal poverty guidelines.
By signing you verify that you meet one or more of the criteria for fee waiver.
Signature*
Check Here if you DO NOT wish MCC to use your photo and/or name in its publicity, marketing, promotion, and advertising efforts as well as in editorial [i.e. brochures, catalog, news releases, academic standing (honors, awards, scholarships) features, etc.
- I DO NOT
Hidden
Colleague ID

For MCC use only

Class Title	Start Date

WDC Form

WDC Registration

Complete if an active volunteer or paid member of EMS, DOC, DPS, Law Enforcement, or Fire Department:

My signature attests that I am actively affiliated with the public safety agency listed and I hold the job classification indicated. Furthermore, I agree to allow my employer to access my academic record.

HRD Tuition and Fee Waiver – Verification Statement