Adult and Continuing Education Registration Form

1
Full Legal Name* This field is required.Please provide your current legal name:
First Name
Middle Name
Last Name
2
Have you attended Trinity Valley Community College before?* This field is required.
YESNO
3
Please provide your TVIN Number or Colleague ID Number:
Ex. 1234567
4
Personal Identification Information* This field is required.Please provide the most accurate information:
Social Security Number
Please Select
Please Select
Female
Male
Gender
Date of Birth
5
Contact Information:* This field is required.Please provide the most up-to-date contact information:
Primary Phone Number
Secondary Phone Number
Email
Street Address
City
State/ Province
Postal / Zip Code
6
In what county do you currently reside?* This field is required.Please choose the county in which you reside or type in the county.
Henderson
Anderson
Van Zandt
Rains
Kaufman
Other
7
Are you Hispanic or Latino?* This field is required.
Yes, I am Hispanic or Latino
No, I am not Hispanic or Latino
8
Please select the racial category or categories with which you most closely identify? * This field is required.Select one or more.
American Indian/ Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
No Response
9
Citizenship Status: Are you a US Citizen, or a permanent resident?* This field is required.
Yes
No
10
If No, what is your country of citizenship?* This field is required.
Type in your country of citizenship.
11
Residency Status: Did you graduate from a Texas high school or receive a GED certificate in Texas?* This field is required.
Yes
No
12
Do you have a military status?* This field is required.
YESNO
13
You answered, yes, to a military status.* This field is required.Please complete the following questions
Military Status
Please Select
Please Select
Yes
No
Are you a disabled veteran?
Please Select
Please Select
Yes
No
Do you receive Veteran Affairs Benefits?
Current/former member of the US Armed Forces
Current/former member of the National Guard
Current/former member of the reserves
Dependent of a veteran
Dependent of a deceased veteran
Dependent of a veteran with a combat-related injury
Military Affiliations (select one or more)
14
Course 1 Information * This field is required.Please provide the following class information to register you.
Course Title
Course Section Number
Course Days/Time
Course Start Date
Course Location
Course Cost
15
Would you like to register for a second course?* This field is required.
YESNO
16
Course 2 Information* This field is required.Please provide the following class information to register you.
Course Title
Course Section Number
Course Days/Time
Course Start Date
Course Location
Course Cost
17
Would you like to register for a third course?* This field is required.
YESNO
18
Course 3 Information* This field is required.Please provide the following class information to register you.
Course Title
Course Section Number
Course Days/Time
Course Start Date
Course Location
Course Cost
19
Would you like to register for a fourth course?* This field is required.
YESNO
20
Course 4 Information* This field is required.Please provide the following class information to register you.
Course Title
Course Section Number
Course Days/Time
Course Start Date
Course Location
Course Cost
21
Would you like to register for a fifth course?* This field is required.
YESNO
22
Course 5 Information* This field is required.Please provide the following class information to register you.
Course Title
Course Section Number
Course Days/Time
Course Start Date
Course Location
Course Cost
23
If you would like to register for more courses, please re-complete another registration form.
24
Please provide a signature to confirm the statement below. The information I have provided is complete and correct to the best of my knowledge. If my application is accepted, I agree to abide by the policies, rules, and regulations at any school to which I am admitted. I authorize TVCC to verify the information I have provided. I further understand that the information submitted herein will be relied upon by the officials of TVCC in determining my admission and residency status for tuition purposes and that the submission of false information is grounds for rejection of my application, withdrawal of acceptance, cancellation of enrollment, and/or disciplinary action.
Clear
25
Trinity Valley Community College considers the name, address, telephone, date of birth, degrees earned and dates, major field of study, dates of attendance, enrollment status, student classification and name of the most recent previous institution attended, number of hours complete and, in progress, directory information. This is done in compliance with the Texas Open Records Law.If you do not want this information released, please check the box below.
I do not want this information released.
26
Trinity Valley Community College does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs or activities.

For questions or concerns regarding discrimination based on sex, including sexual harassment, contact: Director of Human Resources/Title IX Coordinator, 100 Cardinal Drive, Athens, TX 75751, 903-675-6215, humanresources@tvcc.edu.

For questions or concerns regarding discrimination based on a disability, contact ADA/Section 504 Coordinator, 100 Cardinal Drive, Athens, TX 75751

903-670-2068, disability@tvcc.edu.

Revised 1/26/2022
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