NON-CREDIT REGISTRATION FORM
Last Name First Name Middle Name
Address City State Zip
Home Phone Cell Phone Email Address
Date of Birth (MM/DD/YYYY) SSN - - OR Massasoit Student ID#
Have you attended Massasoit Community College before? Yes No If yes, when?
Gender Male Female
Veteran Dependent of Veteran Member of Armed Forces
Do you consider yourself to be Hispanic/Latino? Yes No
Please select one or more of the following that best describes you:
American Indian/Alaska Native Asian
Black/African American Cape Verdean
Haitian Native Hawaiian/Pacific Islander
White/Caucasian
If you have a disability for which you believe you need a reasonable
accommodation, please contact Disability Services at x1807.
Fall _______ (year) Spring _______ (year) Summer _______ (year)
Brockton Campus
One Massasoit Boulevard
Brockton, MA 02302
Canton Campus
900 Randolph Street
Canton, MA 02021
Middleborough Center
49 Union Street
Middleborough, MA 02346
massasoit.edu
508-588-9100
CRN COURSE/SECTION COURSE TITLE Course Cost
Withdrawals before the start of the rst class are granted a full 100% refund.
Withdrawals after the rst class are refunded 0-50% depending on the length
of the ecourse. Please be advised that ceasing to attend a class DOES NOT
constitute a withdrawal. If the proper withdrawal form is not completed, a
grade of F (failure) will be recorded.
Community Education
Please note that Massasoit is required by federal guidelines to report a student’s legal gender.
TOTAL AMOUNT DUE
PAYMENT INFORMATION
Cash or Check
Please mail your check along with this registration form to the address listed above.
Cash payments are accepted at both the Brockton and Canton campuses.
Credit Card
Log into your portal account to make payment once you receive your registration confirmation email.
New students will receive their login credentials via email. Students may contact the Student Accounts
Office via phone at 508-588-9100, x1507 to make a payment.
Third Party Payment
Students who are sponsored by third parties must submit, with their registration form, a letter of
authorization from their agency indicating the amount of the sponsorship and billing information.
Payment Plan
Payment plan options are offered. Check the online schedule for availability at mycollegepaymentplan.com/massasoit.
Once students receive their registration confirmation, they can then activate their payment plan agreement.
Completed forms may be submitted by mail,
in-person, or by fax or email.
Mail to: One Massasoit Boulevard
Attn: Student Central
Brockton, MA 02302
In Person: deliver to Student Central in the
Student Center, Brockton Campus
Fax: 508-427-1246
Email: registrar@massasoit.mass.edu
X
2019
Student Signature Date
Basic Life Support for Healthcare Providers
click to sign
signature
click to edit
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