REGISTRATION FORM
Horry County Adult & Community Education

Last Name: 

First Name: 

Middle/Maiden Name: 

Address: 

City:          State: 

Parent/Guardian (if student under 18): 

Emergency Contact Person/Number: 

Home Phone:    Cell Phone: 

Work Phone:     Age: 

Date of Birth:   (mm/dd/yyyy)     Gender: MaleFemale 

Email: 

COMMUNITY EDUCATION CLASSES

CLASS 1

Month:      Class/Number: 

Time of Class:      Fee: 

CLASS 2

Month: Class/Number:

Time of Class: Fee:

CLASS 3

Month: Class/Number:

Time of Class: Fee:

Special Instructions or concerns that our instructors should be made aware of:  (example:  food allergy, medical conditions, individual needs)

COMPUTER LITERACY CLASSES

Select Class: Mondays/Wednesdays 8-9 amMondays/Wednesdays 1:30-2:30 pmMondays/Wednesdays 5-6 pmThursdays, 3-5 pm

Select Start Date for Monday/Wednesday Classes: February 13March19

Select Start Date for Thursday Classes: February 16March 22