Human Resources Development Registration Form 2023

Human Resources Development Registration Form 2023
Instructor
Class Number
Class Title
Student Information
Student ID #
Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Date
Age*
Street Address*
Apartment/Unit
City*
State*
Zip Code*
County of Residence*
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Business Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Gender

MaleFemale
Race

American/Alaska NativeAsianBlack/African AmericanWhiteHispanic/LatinoHawaiian/Pacific Islander
High School Graduate

YesNo
If No, List the Highest Grade Completed
High School Name and Location (For 16-18 years only)
Highest Level of Education

GED DiplomaAdult HSOne-Year Vocational DiplomaAssociate DegreeBachelor's DegreeMaster's Degree or Higher
Employment Status*

Full-TimePart-TimeRetiredUnemployed (seeking)Unemployed (not seeking)
Emergency Contact
Name
Relationship
Phone
HRD Tuition and Fee Waiver Verification Statement and Signature
The State Board of Community Colleges grants permission to waive tuition and fees for enrollment in classes coded in the Master Course List as Human Resources Development if the individual meets one of four criteria listed below. To receive this waiver, an individual must verify that he or she meets at least one of the criteria by completing and signing this form. Individuals not signing this form must pay the applicable fee to register for a Continuing Education course.
I qualify for a tuition and fee waiver under the following criteria: (PLEASE CHECK ONE OPTION)*

1 = I am currently unemployed.2 = I have received notification of a pending layoff.3 = I am working & eligible for the Federal Earned Income Tax Credit.4 = I am working & earn wages at or below two hundred percent (200%) of the Federal Poverty Guidelines.
I hereby verify that all the information given by me as written on this Registration Form and on this HRD Tuition and Fee Waiver Statement is complete and accurate to the best of my knowledge.
Signature*

Clear
Date

MonthDayYear
Date
2022 HRD Tuition and Fee Waiver Guidelines
200% OF THE FEDERAL POVERTY GUIDELINES

Federal Earned Income Tax Credit

Criteria	Earned Income Threshhold
Individual	$24,210
Worker with one qualifying child	$53,120
Worker with two qualifying children	$59,478
Worker with three or more qualifying children	$63,698

Federal Earned Income Tax Credit

https://www.irs.gov/credits-deductions/individuals/earned-income-tax-credit/ earned-income-tax-credit-income-limits-and-maximum-credit-amounts

200% of the Federal Poverty Guidelines: May 3, 2023

https://aspe.hhs.gov/system/files/aspe-files/107166/2020-percentagepoverty-tool.pdf https://aspe.hhs.gov/poverty-guidelines

200% OF THE FEDERAL POVERTY GUIDELINES

(Actual Guidelines on Federal Register listed at 100%)

Family Unit	200% of Poverty Guidelines
1	$29,160
2	$39,440
3	$49,720
4	$60,000
5	$70,280
6	$80,560
7	$90,840
8	$101,120
For each additional person, add $4,720

HR Director Email
example@example.com
Should be Empty:

Human Resources Development Registration Form 2023

Student Information

Emergency Contact

HRD Tuition and Fee Waiver Verification Statement and Signature

200% OF THE FEDERAL POVERTY GUIDELINES

Federal Earned Income Tax Credit

Federal Earned Income Tax Credit

200% of the Federal Poverty Guidelines: May 3, 2023

200% OF THE FEDERAL POVERTY GUIDELINES