Human Resources Development Registration Form HRD Registration Name(Required) First Last Middle Name(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands County Home Phone:Work Phone:Cell:Date of Birth:(Required) Email:(Required) Employment Status:(Required) Retired Unemployed (Not Seeking) Unemployed (Seeking) Employed (1-10 hours per week) Employed (11-20 hours per week) Employed (21-39 hours per week) Employed (40+ hours per week) High School Last Attended Date (Month/Year):(Required)Highest Level of Education:(Required) Did Not Complete - If this is selected, enter grade below GED Diploma High School Diploma Adult High School Diploma Vocational Diploma Associate Degree Bachelor's Degree or higher If you did not complete, enter last grade completed here:HRD Course InformationCourse Title:(Required)Course Number:(Required)Date(s):(Required)Schedule Meeting Time:(Required)HRD Tuition and Fee Waiver Verification Statement and SignatureI qualify for a tuition and fee waiver under the following criteria (PLEASE CHECK ONE OPTION)(Required) 1 = I am currently unemployed (See below for required follow up information) 2 = I have received notification of a pending layoff (See below for required follow up information) 3 = I am working & eligible for the Federal Earned Income Tax Credit (See below for required follow up information and calculation guidelines to determine eligibility) 4 = I am working and earning wages at or below two hundred percent (200%) of the Federal Poverty Guidelines (See below for required follow up information and calculation guidelines to determine eligibility) The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in classes coded in the Master Course List as Human Resources Development if the individual meets one of the four criteria listed below. To receive this waiver, an individual must verify that he or she meets at least one of the criteria by completing and signing this form. Individuals not signing this form must pay the applicable fee to register for a Continuing Education course. Last 4 digits of Social Security Number or Student ID:(Required)Gender:(Required) Male Female Ethnic Origin (Check One):(Required) Hispanic (HIS) Non-Hispanic / Latino (NHS) If you selected NHS, please complete the following RACE section: Race (Check One):(Required) Asian (AS) Caucasian (WH) African American (BL) Alaskan Native / American (AN) Hawaiian / Pacific Islander (HP) If you checked No. 1 - If unemployed, please give the name and location of the company last employing you and your last date of employment: COMPANY NAME:Location:Last Date of Employment:If you checked No. 2 - If you have recieved notification of a pending layoff, please give the name and location of the company: COMPANY NAME:Location:If you checked No. 3 or 4 on reverse side: Employer / Job TitleStart Date End Date Weeks Employed Per YearHourly WageHours Per WeekNumber of dependents in your household:Comments:2026 HRD Tuition and Fee Waiver GuidelinesIf the student's charges are being paid by an outside organization, WPCC must have the student's consent to release their educational records including but not limited to, transcripts, student's identification numbers, course listings, and charges that have been authorized to be paid through an outside organization. I certify that the information on this application is correct. I agree to abide by the rules, policies and regulations of the College during my enrollment at Western Piedmont Community College. I also verify that the information completed in regards to the HRD Tuition and Fee Waiver Verification is complete and accurate to the best of my knowledge. The college has my permission to release pertinent information on this form to appropriate college staff and, in the event of emergency or illness, I give permission to call a local physician, also if this class is for certification, by affixing my signature below, I grant permission to release the appropriate course information to the certifying agency. Please be advised that WPCC cannot register you for any class if you have an outstanding debt with the college. Student Signature(Required)Date(Required)
