GREAT BAY COMMUNITY COLLEGE (GBCC)
ENROLLMENT FORM
ADULT
STUDENT
Assumption of Risk and Liability Release
Please fill out this form and take it with you to Great Bay Community College
Present it to the One Stop along with your signed, course registration form
_________________________________________________________________________________________________
Participating Student Last Name First Name Middle Name
_________________________________________________________________________________________________
Date of Birth:
MM/DD/YYYY Home Phone Email
Grade Level: 11
th
12
th
Goal College: __________________ Goal Career: ____________________
_______________________________________________ Anticipated Graduation Date: _________/____/__________
High School Name
Type of School: Public High School Private School Home School
GBC
C term student is scheduled to attend: Fall Spring
Summer Year: ______
Hig
h School Counselor recommended GBCC course(s):
_________________________________________________________________________________________________
GBCC Course Name and Number GBCC Course Title
_________________________________________________________________________________________________
GBCC Course Name and Number GBCC Course Title
*Limit of two classes per semester*
STUDENT APPROVAL:
1. Credit courses are COLLEGE courses and will remain on the student’s permanent college record.
2. I understand that the College will have specific rules that will apply to the student's ability to enroll and
attend. These rules may include, but are not limited to, certain enrollment prerequisites, registration
requirements, placement tests, matriculation status, and access to "remedial" or "developmental" courses.
3. I understand that there will be no supervision provided for students prior to or after classes.
4. I understand that the coursework has college level content which may include mature material.
5. I understand that the College is authorized to evacuate students in case of an emergency.
6. I understand I must adhere to the College’s Student Code of Conduct.
7. I represent that I am 18 years of age or older.
8. I understand that I am responsible to pay 50% of the actual tuition for GBCC courses. I also understand I am
responsible for the cost of books and materials and associated fees.
9. I understand that the Family Education Rights and Privacy Act (FERPA) governs all college records and allows
release of academic information, including grades, to the student only. Academic information cannot be
released to parents or third parties without the written consent of the student.
10. To the extent permitted by law, I release, hold harmless, indemnify and covenant not to sue the CCSNH and
its colleges and/or their governing boards, trustees, employees and any agents from and against any and all
liability for harm, injury, damage, claims, demands, actions, causes of action and expenses of any kind that I
may have or that may hereafter accrue to me, directly or indirectly, related to any loss, damage or injury
sustained through my participation at the College.
_________________________________________________________________________________________________
Participating Student Signature Date
HI
GH SCHOOL COUNSELOR APPROVAL:
1. The student listed is a Junior or Senior and is a regularly enrolled student at our school and has permission to
take the above course(s) at GBCC.
2. The student is able to benefit from advanced scholastic or vocational work at GBCC.
3. The GBCC course(s) selected will also satisfy a high school requirement.
Guidance Counselor Name (Please Print) Phone
_________________________________________________________________________________________________
Guidance Counselor Signature Date
High School Phone: ________________________
For Information or Questions:
Office of Admissions
603-427-7600 Ext 7500
GBAdmissions@ccsnh.edu
For Returning Students:
Advising Center
603-427-7728
greatbayadvising@ccsnh.edu
For Office Use Only:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
The Community College System of New Hampshire (CCSNH) uses electronic signatures and records in place of traditional ones whenever possible. You will conduct business electronically using a computer with a supported
operating system and internet browser, sufficient electronic storage capacity, a printer and your official CCSNH email account. By logging into CCSNH systems, including but not limited to Banner, SIS and Canvas, you are opting to
conduct electronic transactions with the Community College System and consenting to receive written notices electronically, including those involving financial obligations, and you are acknowledging that CCSNH can use
electronic mechanisms alone to convey critical information related to your admission, financial aid, payment plan, student account, transcript information, registration and other activities and accounts you may undertake or have as
a student at CCSNH. You have a right to request a paper copy of an electronic record. You may withdraw your consent at any time by contacting Student Services. If you decide to withdraw your consent, however, you may be
prevented from registering for classes.
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