Med Aide Renewal Registration Form

Student Name*

First NameMiddle NameLast Name

Social Security Number*

Birth Date*

MonthDayYear

Phone Number*

Format: (000) 000-0000.

Email*

example@example.com

Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Courses

MA Number*

Do you have a High School Diploma or GED?

YesNo

Are you enrolled in a developmental class or Adult Basif Education (ABE) because of TASP or placement scores?

YesNo

Are you receiving a Pell Grant or other Federal Assistance?

YesNo

Do you have a disability which substantially limits a major life activity?

YesNo

Do you have difficulty speaking or understanding instructions in the English language?

YesNo

Are you a homemaker no longer supported by public assistance and having difficulty obtaining employment?

YesNo

Are you a single parent?

YesNo

All students are responsible for adhering to the rules and regulations set forth in the Howard College Student Handbook.

I understand I can withdraw form the class under the following Continuing Education guidelines for withdrawals:

1. Prior to the first class day 100% refund

2. Prior to the second class day 70% refund

3. Second class day and beyond 0% refund

The withdrawal process includes contacting the Continuing Education office or the Registrar's office during business hours to complete an official drop slip. Please sign and date below indication that you have read and understand the guidelines for withdrawal.

Signature*

Date*

Date

Medication Aide Renewal