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MEDICAL ASSISTING
FALL 2020
REGISTRATION FORM
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INSTRUCTIONS:
Read and complete
Steps 1-4 of the Registration Checklist in the Medical Assisting Information Packet.
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Step 5: Download this form, complete PART 1: STUDENT INFORMATION, and save the file as a PDF. Send the following
items to the Admissions Office for registration:
Registration Form PDF (Part 1 completed) Copy of your government-issued photo ID
Payment confirmation from CastleBranch Copy of your signed social security card
You will receive a conformation once you are registered for the class or a notification
if any items are missing from your course registration.
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Step 6: Registration payment ($180) and insurance fees ($18) are due by August 3, 2020 to the RCC Business Office.
PART 1: STUDENT INFORMATION
COURSE SECTION: MED-3301-01 Medical Assisting
FULL NAME (first/middle/last): _______________________________________________________________
STREET ADDRESS: _________________________________________________________________________
CITY/STATE/ZIP: _______________________________________ COUNTY: ____________________
HOME PHONE: ____________________________ CELL PHONE: ___________________________________
EMAIL: ___________________________________________________
STUDENT SIGNATURE: ______________________________________ DATE: _________________
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Your signature on this document indicates that the information included in your registration packet is correct
and that you have read and understood the program information packet.
PART 2: MEDICAL ASSISTING REGISTRATION CHECKLIST STUDENT ID: _______________
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**This section is to be filled out by RCC Admissions Office staff**
Notes
(Staff Use Only)
Item
Verification
(Staff Use Only)
RCC application on file with the Admissions Office ________ Verified by Admissions Staff
Official high School/GED transcript received by Admissions Office ________ Verified by Admissions Staff
Government issued photo ID (i.e., driver’s license or passport) ________ Verified by Admissions Staff
Signed social security card (first and last name must match driver’s license) ________ Verified by Admissions Staff
Order Confirmation page for a criminal background check from www.castlebranch.com ________ Verified by Admissions Staff
Student registered on RGPE/RGN ________ Verified by Admissions Staff
Admissions Office Staff: _________________________________________ Date: __________________
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