Florence District One Community Education Registration
For all academic courses, please register in room 306 at Poynor

TODAY’S DATE: 

Personal Information: 

I am a:  New Student Returning Student

Last Name:      First Name:    Middle:

Address:  City:  State:  Zip: 

Home Phone:   Work Phone:

In Case of Emergency Contact:   

Emergency Contact Phone:   Relationship:

E-Mail:

Gender: Female Male Race: Asian/Hawaiian Black Hispanic Native White Other (Please Specifiy) Other: 

Date of Birth:    Age:   

Employed:  Full Time Part Time Seeking Employment

Course: Starting Date:    Time:

Cost:   

How did you learn about our programs? Catalog inserted in newspaper Newspaper ad Cable Station Catalog Word of Mouth Other (Please specify) Other: