Workforce Development & Community Education Application

Name *

First

Last

Email *

Birthdate *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number *

Gender *

Male
Female
Not Reported

Race (Select all that apply) *

Ethnicity *

Hispanic/Latino
Not Hispanic/Latino

Employer / Company Name / High School:

Home Phone *

Employer / Company Name / High School Address:

Cell Phone

Please indicate in which classes you would like to be enrolled. Enrollment may be limited and not all classes are offered each term. Be sure to check the non-credit schedule for class dates/times.

Select the class(s)/program(s) you wish to take: *

For EMS courses, please select the class you are enrolling in (classes are not offered every term, please refer to non-credit schedule for class dates/times):

For Fire courses, please select the class you are enrolling in (classes are not offered every term, please refer to non-credit schedule for class dates/times):

Paying for Class:

Payments can be made via check, money order, credit card (Visa, Master Card, Diner, Discover or American Express) or cash. Payment must be received by the Workforce Development and Community Education Department seven days prior to the start date of class to hold your seat. If payment is not received, student is not considered registered.

Withdrawing from Class:

In order to withdraw from class a student must notify the Workforce Development and Community Education Department and state that they will not be attending seven days prior to the start of class. Students who fail to notify the department seven days prior to the beginning of class will be responsible for the entire cost of the class. Belmont College's policy states students are ultimately responsible for the cost of the class. In case of a third party pay, if a student does not attend class or notify the department, the student will receive an invoice for the cost of the class, not the third party.

Notification of Registration:

A student is considered registered for a class upon receipt of their registration form and payment. Every student may consider themselves registered and the class going as scheduled unless they receive notification from the department.

Refund Policy:

100% refund if college cancels, 100% refund if student withdraws seven days or more prior to the start date of class, 50% refund if student withdraws two to six days prior to start date of class, 0% if less than two days prior to the start date of class.

Signature *

Clear Signature