Office Use Only
Continuing Education

Spring
Summer
Registered by:
Mail form to:
Harford Community College
Continuing Education and Training Division
401 Thomas Run Road, Bel Air, MD 21015
phone 443-412-2376 • fax 443-412-2383
Fall
Cashier’s Office:
C/R
Ini.
Date
H
HCC ID
Last Name (Please Print)
First Name
Street
City
Home Phone
Cell/Work Phone (circle one)
MI
State
Zip Code
Email 
Home or 
Business
Contact information for HCC AlertMe Emergency Notification System
YES, please contact me in the event of an emergency on campus or a non-emergency campus closing.
NO, I choose not to be contacted in the event of a campus emergency or non-routine campus closing.
Date of Birth
/
Senior Citizen (60 years or older) YES NO
/
preferred contact phone number
Gender Male Female
month/day/year
Citizenship U.S. Citizen Permanent Resident/Asylee/Refugee (Must bring in original card.)
Non-U.S. Citizen (Must submit copy of immigration document.) Visa Type:
Are you of Hispanic or Latino origin? YES NO
(Defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
Ethnicity
Race
See back for definitions of race.
Select one or more of the following categories: White (01) Black/African American (02) Asian (03)
American Indian or Native Alaskan (04) Native Hawaiian or Other Pacific Islander (05)
How did you hear about this course?
Newspaper Radio HCC Marquee HCC Website Printed Schedule of Classes HCC Kids Summer Program Booklet
Email Postcard/Flyer/Brochure HCC Facebook Referral from Family or Friend Referral from Instructor
Other
COURSE #
COURSE TITLE
Payment is due at time of registration.
 Check  Money Order
 VISA  MasterCard  Discover  American Express
COURSE FEE
MATERIAL FEE
OUT-OF-COUNTY
SURCHARGE $20
OUT-OF-STATE
SURCHARGE $35
TOTAL COST
I accept and agree to abide by the policies and regulations of HCC. I
understand that violation of these regulations may subject me to penalties and
sanctions. (A copy of the Student Code may be obtained from the Student
Activities Office.)
See back for information concerning the Annual Security Report.
We will contact you to take payment
as soon as your registration has been
processed.
I certify that the information on this form is accurate and complete. Failure to
provide accurate information may be just cause for dismissal from the College.
Signature
Date
Definitions for Race:
o White: A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
o Black or African American: A person having origins in any of the black racial groups of Africa.
o Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam.
o American Indian or Alaska Native: A person having origins in any of the original peoples of North
and South America, including Central America, and who maintains cultural identification through tribal
affiliation or community attachment.
o Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
Annual Security Report (ASR):
The Annual Security Report contains three consecutive years of campus crime statistics and information on
how to help keep individuals and their property safe on campus. It is published and available annually by
October 1st. A hard copy may be requested in writing, by phone, or in person at the Department of Public
Safety, 443-412-2272, located in the first floor of the Library at 401 Thomas Run Road, Bel Air, MD 21015.
The Annual Security Report can be accessed electronically at http://www.harford.edu/~/media/PDF/publicsafety/15-0123_Annual_Security_Report_2014-Interactive.ashx