If you would like to download the form and send it to the Pee Dee AHEC, please click on the link below. If you would like to continue to use the online version of the form, simply fill out the information below.

HPS Student Registration Form

Fill the form out completely. Uncompleted forms will be discarded. To move the form, click and hold on the word move in the top right hand corner and drag it where desired.

Fields marked with a * are required.

* Your Participant ID:
Your 8 digit Participant Identification number is made up of: 2 digits of your birth month (01-12), 2 digits of your birth day (01-31), and the last four digits of your Social Security Number. This identifier protects your personal information in our database and allows us to provide you credit for our courses.
Example: The Participant ID for someone born 11/21/1989 with the SSN 123-456-7890 would be: 11/21/7890

* Your First Name:

Your Middle Name:

* Your Last Name:

Your Maiden Name:

Suffix:

* Your Email:

* Your Address:

* City:

* State:

* Zip Code:

* County:

Phone Number 1:

Phone Number 2:

Fax Number:

Date of Birth:

* Your Primary Language:

Other Primary Language (if applicable):

Your Ethnicity (Check if applicable):
Please check one below if applicable
Hispanic or Latino

* Your Race:

* Are You From a Disadvantaged Background?:

* Gender:

* What is type of neighborhood you live in?: