For Office Use Only
VIRGINIA COMMUNITY COLLEGE SYSTEM
NONCREDIT APPLICATION FOR ADMISSIONS AND REGISTRATION
Paul D. Camp Community College
Empl ID _________________
Staff’s Initials ____________
Encore Learning
Date ___________________
General Information:
1. If you have and/or know your Virginia Community College Empl ID, please provide:
2.
Name: ___ Mr. ___ Miss ___ Ms. ___ Mrs. ___ Other
3.
Full First
4.
Social Security Number: _______ - _______ - ________
6.
Date of Birth: _____ / _____ / _____
9.
Mailing Address:
Full Middle
Full Last
Suffix (Jr., Sr., II, III, other)
5. Former Name: ______________
______
_
7. Home Phone: (_____) ______ - _______ 8. Cell Phone: (_____) ______ - _______
Street
Apt./Suite
City
State
Zip
10. If you live in Virginia, provide your jurisdiction (city or county):
11. If you live outside of Virginia, provide the state and/or country:
12. Email address:
Citizenship Information:
13. Are you Hispanic or Latino: ____ Yes ____ No
16. Gender: ____ Male ____ Female
17. Racial/Ethnic Group: ____ American Indian/Alaska Native ____ Asian ____ Black/African American ____ White
Native Hawaiian/Other Pacific Islander
18. What is your citizenship status? ____ Native (U.S. citizen at birth), ____Naturalized (became U.S. citizen after birth)
____ Alien Permanent, ____ Alien temporary, ____Not living in the U.S.
19. Primary Language ____ English _________________ Other
Military Information:
20. _______ None ______ Active ______ Active Reserves ______ Inactive Reserves ______Retired ______ Veteran ______ Military Spouse
21. Date entered into military: ____/_____/_____
22. Date retired from military: ____/______/______
Encore Membership & Registration:
√
Encore Membership Selection
Spring 2016
(Feb– May)
Fall 2016
(Sept – Dec)
Cost
Single Term Membership
$30
Year Membership (Two Terms)
$50
Individual course registration is on pages 3- 4 of this form. Membership is $30 per term ($50 for two terms) and payment must be
paid at the time of registration. Some classes have limited registration and will be filled on a first come/first served basis.
Method of Payment (please circle):
Cash
Check
Money Order
VISA
MasterCard
This institution promotes and maintains educational opportunities without regard to race, color, sex, ethnicity, religion, gender, age (except when age
is a bona fide occupational qualification) handicap, national origin or other non-merit factors.
100 N. College Drive, Franklin, VA 23851
Phone: 757.569.6700, Fax: 757.569.6055
www.pdc.edu/workforce-development/encore-learning/
Revised 9/18/2015
VIRGINIA COMMUNITY COLLEGE SYSTEM
NONCREDIT APPLICATION FOR ADMISSIONS AND REGISTRATION
Paul D. Camp Community College
Encore Learning
PHOTOGRAPHY RELEASE
I give permission to Paul D. Camp Community College to use photographs of me for college publications or advertisements in print or
electronic media. I consent to the use of my name, likeness, voice, and biographical material about him/her in connection with college
publicity or institutional purposes.
Signature: _________________________________________________ Date: ___________________
EMERGENCY INFORMATION
In the event of an emergency, accident, injury, etc., please contact the person(s) below:
Emergency Contact: _________________________________________________
Street Address: _______________________________________ City: ___________________________ Zip: _________________
Home phone: ________________________________________
Cell phone: ______________________________________
If the above person cannot be reached, please contact:
Emergency Contact: ______________________________________________
Street Address: _______________________________________ City: ___________________________ Zip: _________________
Home phone: ________________________________________
Cell phone: ______________________________________
Your Physician: ___________________________________________
Physician’s phone: __________________________________________
Medical Release and Liability Waiver - Please read carefully before signing
The undersigned hereby acknowledges that participation in Paul D. Camp’s Encore Learning program may involve a small but inherent
risk of physical injury, and the undersigned hereby assumes all such risk and does hereby release and forever discharge the Encore Learning
staff, instructors, Paul D. Camp Community College and all agents thereof from any and all liability of whatever kind or nature, arising from
and by reason of any and all known and unknown, foreseen and unforeseen, bodily and personal injuries, damage to property, and the
consequences thereof, resulting from the registrant’s participation in or involvement with this course. It is strongly recommended that you
obtain approval from your physician prior to participating in the activities of this course.
Signature: ___________________________________________________________________________
Volunteer Opportunities
Would you be interested in teaching a course?
□ Yes □ No
If yes, possible topic(s): _______________________________________________________
We need volunteers in all capacities to help us with our Encore Learning programming. Check all the areas where you would be willing to
help:
 Administrative support
 Program development (class/instructor selection)
 Catalog development/distribution
 Hospitality
 Website
 Travel (driver, trip planning, etc.)
 Other _____________________________________________
I certify that all of the above information is complete and accurate. I agree to supply the college with supporting documentation
related to my application, if I am requested to do so.
Signature: _________________________________________________
Date:
VIRGINIA COMMUNITY COLLEGE SYSTEM
NONCREDIT APPLICATION FOR ADMISSIONS AND REGISTRATION
Paul D. Camp Community College
Encore Learning: Spring 2016 Term Course Listing
Name: ______________________________
EMPL Id: _____________
√
Course
Brushstrokes: Spring Landscape
Paintings
Let’s Go to the Movies!
The Bible on Trial: Beyond a
Reasonable Doubt
Understanding Opera:
Romeo & Juliet
Understanding Opera:
The Flying Dutchman
Date
Time
Instructor/Docent
February 17
1p – 2p
Twyla Duke, RMA
10a – 11a
Nancy Warren, PDCCC
Tuesdays
March 8, 15 & 22
Tuesdays
Feb 11, 18, 25 &
March 3
2p – 3p
Rev. Dennis Rhodes
January 26
10a—11a
March 29
10a—11a
Glenn Winters
Virginia Opera
Glenn Winters
Virginia Opera
Getting Oodles from your Googles
Mondays
Feb 1 - March 7
3p—5p
Dave Vickers
Introduction to the PC
Wednesdays
Feb 3— April 6
3p—5p
Dave Vickers
Mondays
March 14 - April 18
3p—5p
Dave Vickers
Blackwater Outfitters
Blackwater Outfitters
Power Surfing the Internet for
Your Ancestral Roots
Pond Paddlin' : Beginning Kayaking
March 23
Pond Paddlin' : Beginning Kayaking
April 7
1p—3p
1p—3p
Pond Paddlin' : Beginning Kayaking
April 13
1p—3p
Blackwater Outfitters
Pond Paddlin' : Beginning Kayaking
River Paddlin’
(2.5 mile paddle trip)
River Paddlin’
(2.5 mile paddle trip)
River Paddlin’
(2.5 mile paddle trip)
River Paddlin’
(2.5 mile paddle trip)
The Art of Healthy Aging Forum
and Expo
Family Tree Climbers:
Intro to Genealogy
Family Tree Climbers:
Intro to Genealogy
Frosting & Friends: Cookies &
Cupcakes
Frosting & Friends: Cookies &
Cupcakes
May 5
1p—3p
Blackwater Outfitters
1p—3:30p
1p—3:30p
Blackwater Outfitters
April 21
Blackwater Outfitters
April 27
1p—3:30p
Blackwater Outfitters
May 11
1p—3:30p
Blackwater Outfitters
May 19
Saturday, April 9
9a—2p
Senior Services of SEVA
Wednesdays
Feb 17, 24 & Mar 2
3p – 5p
Kristy Edenfield
Tuesdays
April 5, 12 & 19
3p – 5p
Kristy Edenfield
February 25
11a – 12p
Terry Edwards
March 31
11a – 12p
Terry Edwards
Happy Feet: Basic Line Dancing
Mah Jongg Madness
Sit and Be Fit: Chair Aerobics
Sit and Be Fit: Chair Aerobics
Kandi Turner
Wednesdays
Tuesdays
Feb 9 – Mar 1
Tuesdays
April 5 – April 26
1p – 3:30p
Linda Johnson
10a – 11a
Teri Zurfluh
10a – 11a
Teri Zurfluh
VIRGINIA COMMUNITY COLLEGE SYSTEM
NONCREDIT APPLICATION FOR ADMISSIONS AND REGISTRATION
Paul D. Camp Community College
Encore Learning
Spring 2016 Term Course Listing
Name: ______________________________
Course
EMPL Id: ______________
Date
Time
Instructor/Docent
Tuesdays
11a – 1p
Bruce Saunders
Wednesdays
Feb 10—April 27
11a – 12p
Teri Zurfluh
Advance Care Planning Made Easy
April 29
10a – 12p
David Murray
Be Heart Healthy!
May 17
11a – 12p
March 10
1p
Dianne Vick, SMH
Chef Estine Rusk &
Joe Marlowe
February 9
1p
William D. Rieley
February 18
11a – 12p
Encore Staff
April 7
11a – 12p
Encore Staff
May 12
11a – 12p
Encore Staff
May 18
8:30a – 5p
Kathy Mountjoy
April 20
8:30a – 5p
Kathy Mountjoy
March 1
2p – 4p
RMA staff
February 26
9a—4p
Yarn Spinners:
Knitting and Crocheting Club
The Zen of Coloring:
Encore Coloring Club
The Encore Kitchen: Cooking with Heart
Our Virginia Heritage: Nature and Geometry
in the Jeffersonian Landscape
Encore Onscreen: American Ride
(George Washington & Abraham Lincoln)
Encore Onscreen: American Ride
(Adams & Jefferson)
Encore Onscreen: American Ride
(Theodore Roosevelt & Franklin D. Roosevelt)
Encore on the Go! Art in the Gardens:
Agecroft Gardens & VMFA
Encore on the Go! The Garden Cemetery:
Hollywood Cemetery
Art in the Afternoon: A Day at Rawls Museum
Arts
Portrait of a Collector:
Wayland L. Jenkins, Jr. Fine Arts Center
Twyla Duke
Defining the Cold War
March 5
2p
Monster Matinee
March 13
1p
May 15
1p
Isle of Wight County
Museum Staff
Isle of Wight County
Museum Staff
Isle of Wight County
Museum Staff
March 17
TBD
Chowan University
Put the Genie Back in the Bottle
Encore Extras!
SeniorFest 2016
Is there someone you know who would enjoy Encore Learning? Feel free to share their contact
information below and we’ll send them an Encore Learning Welcome packet!
Name: ____________________________________________________
Email: ____________________________________________________
Phone: ___________________________________________________
May we tell them that you recommended them for our Welcome packet?
 Yes, of course
 I would prefer you not use my name