EARLY COLLEGE REGISTRATION FORM
31 College Dr, Concord, NH 03301
Mark Bograd, Coordinator of High School Outreach (603) 230-4029 - mbograd@ccsnh.edu
Registrar’s Office (603) 230-4014 – Fax – (603) 230-9314 – nhtiregistrar@ccsnh.edu
Student ID: ___________________ Semester: Fall Spring Summer Year: _______________
Last Name: ____________________________First Name: ____________________________Middle Name:____________________
Mailing Address: _________________________________ City: __________________________ State: _______ Zip:___________
Home Phone: __________________________________________ Cell Phone: ____________________________________________
E-Mail Address:____________________________________ *Social Security #:XXX-XX-______ (Last 4 digits only)
*For compliance purposes, the Community College System of New Hampshire and its Colleges collect names and social security numbers from all
students attending the college. For example, the Internal Revenue Code requires the college to produce a 1098-T tax form. The college’s use of social
security numbers will be limited to legitimate educational purposes. The college will exercise due diligence to protect the security of the student’s social
security number and will not disclose it to anyone outside the college, except as authorized by federal or state laws or applicable policies.
Federal Governmental Statistical Information (Optional): Sex: ___F ___M Date of Birth: / /
Ethnic Background: Hispanic or Latino Not Hispanic or Latino
Select one or more races: American Indian/Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
Tuition for Early College is $322.50 for a 3 credit course and $430 for a 4 credit course; books and supplies are not included.
Financial Obligation Statement -- I agree that by registering for courses within the Community College System of New Hampshire (CCSNH), I am
financially obligated for ALL costs related to the registered course(s). Upon a drop or withdrawal, I agree that I will be responsible for all charges as noted
in the student catalog and handbook. I further understand that if I do not make payment in full, my account may be reported to the credit bureau and/or
turned over to an outside collection agency. I also agree to pay for the fees of any collection agency, which may be based on a percentage of the debt up to
a maximum of 35%, and all additional costs and expenses, including any protested check fees, court filing costs and reasonable attorney’s fees, which will
add significant costs to my account balance.
NHTI Refund Policy -- Students who officially withdraw from NHTI or an individual course by the end of the fourteenth (14th) calendar day of the
semester will receive a 100% refund of tuition, less nonrefundable fees. Students in classes that meet in a format shorter than the traditional semester (15-
16 weeks) will have seven (7) calendar days from the designated start of the alternative semester to withdraw for a full refund, less non-refundable fees. If
the seventh (7th) or fourteenth (14th) calendar day falls on a weekend or holiday, the drop refund date will be the first business day following the weekend
or holiday. Exception: students in courses that meet for two weeks or fewer must drop by the end of the first day of the class in order to receive a 100%
refund, less non-refundable fees. [Please note that certain fees are non-refundable. Non-refundable fees are defined as advance tuition deposits, admission
application fees, residence hall room deposits, payment plan fee, orientation fees. All other fees are to be considered refundable. This includes, but is not
limited to academic instruction fees, lab fees, comprehensive student services fees, and the Nursing, Dental, and Diagnostic Medical Imaging Program
clinical surcharges.]
____________________________________________ __________ ____________________________________________ _________
Student Signature Date Parent/guardian signature Date
(Required if student is under 18)
METHOD OF PAYMENT
Credit Card if paying in FULL (please note a 2.75% convenience fee will be charged):
Card Type: Master Card VISA Discover
Name on credit card: _______________________________________________
Acct #: __________________________________________________________
Exp Date: ____________________ Phone:____________________________
Billing Address: ___________________________________________________
City: _____________________________ St: _______ Zip: _________________
Signature: _______________________________________________________
Cash (do not mail)
Check Attached Payable to: NHTI, Concord’s Community College
The Governor’s STEM Scholarship: Students from participating NH high schools may be
eligible for a scholarship equal to 2 CCSNH dual enrollment (Early College, Project Lead the Way,
Running Start) courses per academic year in designated STEM field courses.
Payment is due at the time of registration.
Registration will NOT be processed if you have an outstanding obligation to CCSNH. Upon
registration, you are enrolled unless otherwise notified. No confirmation will be mailed.
Classes are subject to change. Students need to check the SIS for their schedules, classroom
location(s), grades, semester charges, student email account, etc.
Revised 02/19
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