Howard Community College

I certify that the information I have provided on this form is accurate and complete. By proceeding with this registration, the registered student above and I agree to abide by all HCC and KOC policies. I understand and agree that I am responsible and obligated to pay for all KOC courses and fees for the above student. Past due balances are subject to collection and fees. * Parent/Guardian Signature * Date * required CREDIT CARD INFORMATION: Students who register by mail or fax will receive an email registration confirmation; valid email required (printed confirmations no longer mailed). (check one) Visa Mastercard AmEx Discover Kids on Campus Registration Form Registration Opens January 30, 2020 Please complete all information (incomplete forms cannot be processed) . PLEASE PRINT NEATLY. Card# Expiration Date Cardholder's Name (Please print legibly) Signature *Students who receive more than half of their financial support from others should list the address of such person(s) if different from student's home address. Student ID#: (for returning students only) _________________________________________________________________________ KOC Parent/Guardian Email Address: __________________________________________________________________________ Student Name: (Last) _________________________________ (Full First Name) __________________________________________ Address: (Street) ________________________________________________________________________________________ City ___________________________________________________ State ________Zip: ___________ County: ______________ Home Phone: ___________________________________ KOC Parent Cell Phone: _____________________________________ KOC Parent Business Phone: ____________________________ Student Date of Birth: ________________________________ Student Gender: Male Female Check if information has changed since last registration. / / • Are you of Hispanic or Latino origin? Yes___ No___ • What is your race? Select one or more of the following categories: ___American Indian or Alaska Native ___Asian ___Black or African American ___White ___Native Hawaiian or Other Pacific Islander (For race definitions, visit howardcc.edu/categorydefinitions) INDEX # COURSE NO. & SECTION TITLE DATE/TIME TUITION Out-of-county Maryland residents add $10 per course. Residents outside Maryland add $20 per course. TOTAL COURSE INFORMATION:

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