CE Registration Form
ACC CONTINUING EDUCATION REGISTRATION
Date:__________
| | |
Last Name First Date of Birth Social Security Number/ID Email Address
Mailing Address
City
Name of Course
Sample Þ
Room
Numbers may
change and will
be posted the
first day of
class
Course
Prefix
Home/Cell Phone #
Work Phone #
HART
Course
Number
1071
Synonym
Number
89850
Section
Number
200
Campus
RVS
Tuition
$475
Lab Fees
$25
Other Fees
$3.50
HPRX
3012
n/a
$20
n/a
n/a
Start Date
01/28
Pain Management
Solar Electric Installation
Zip Code
State
Subtotal ACC Parking Permit fee (needed for classes at ACC campuses that are over 30 hrs and 4 weeks long ) - $10.00 fee
ACC Parking permit valid from Sept 1 - Aug 31 Total Fees, Tuition & Parking (payment due at time of registration)
Please Check One: (for State Reporting Purposes)
$ 20
Ethnicity: Gender:
š Hispanic/Latino š Female
š Black/African American š Male
š Asian
š American Indian/Alaskan Native
š Native Hawaiian/Pacific Islander
š White
š Other
Students with disabilities that need
accommodations should contact ACC’s Office for Students with Disabilities at (512) 223-2026 or
TTY 512-223-2019 or visit www.austincc.edu/osd for more information.
Family Education Rights and Privacy Act of 1974
The following statement concerning student records maintained by Austin Community College is published in compliance with the Family Education Rights and Privacy Act of 1974. The release of information to
the public without the consent of the student will be limited to that designated as directory information. Directory information includes name, address, telephone number, date and place of birth, major field of
study, participation in activities, dates of attendance, degrees, certificates and awards, and name of most previous educational institution attended. Any student objecting to the release of all or any portion of such
information must notify the Office of Admissions in writing and the restriction will remain in effect until revoked by the student.
No receipt will be mailed, please call if you need confirmation of your class registration. Please note that Insurance Fees are non-refundable after
first class day.
_______________________________________________________________________________________________
Signature Date
Payment is due at the time of registration. Please make payment with cash, check, or credit card at any of the ACC Campus Cashier offices
within 24 hours after registering for courses. We currently accept Visa, MasterCard, American Express or Discover. Payment must be received
within 24 hours to avoid being dropped from class.
Automated telephone registration: (512) 407-3087 or toll-free (866) 878-7889. Online registration: www.austincc.edu/ce/register
Austinwill
Community
College
Continuing
Education
• Attn:form
CE • 5930
Middle
Road
Austin, TX
78752 • (512) 223-7542 • www.austincc.edu/ce
Mail-in payments
be accepted
with
completed
registration
in the
formFiskville
of check
or• money
order.
CE 09-08