Student Course Registration Form

Please specify the Course Name and Start Date you are registering for:

Name

First NameLast Name

Birth Date

Date

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Form of Payment

Other

Please indicate your Employment Status:

Please indicate Highest Level of Education:

Are you currently enrolled in College?

How did you hear about our class?

You may be eligible for grant funding to cover your tuition for this course.

Are you a Somerset or Hunterdon County resident that is:

Unemployed / Receiving Public Assistance
US Veteran / Spouse of Active Military
Displaced Homemaker
Recently Laid Off
Out of school youth (ages 18-24)
To inquire about your eligibility status and begin the process for tuition coverage, please contact OneStop@SomersetCountyNJ.gov
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Contact the Program Administrator, Shannon Woodruff, for questions regarding our courses:

Shannon.Woodruff@raritanval.edu

908.648-8371