Mail completed registration form along with your payment to:
North Shore Community College, Enrollment & Records Office, 1 Ferncroft Road, Danvers, MA 01923-08402
Or, fax (with your Visa, MasterCard, or Discover Card number) to: 978-762-4015
Last Name:
First Name:
Middle Initial:
Street:
City:
State:
Zip Code:
Home Phone: ( )
Cell Phone: ( ) ext.
Email Address:
Student ID #:
(if known)
CRN Course Code Sec Course Title Day Time Noncredit Course Cost
Mail-in /Fax-in Registration Form – Professional Education
BE SURE TO REGISTER EARLY FOR BEST SELECTION OF CLASSES!
REGISTRATION FORM
Please complete all questions
on this registration form.
Semester/Year:
Date of Birth:
(Required)
High School Name:
High School Graduation Year: GED: Yes No
Please fill the appropriate circle for demographic purposes:
1- Gender: ........................................ M F
2- US Citizenship: .................................. Yes No
If no, are you a Resident Alien (Green Card)? ......... Yes No
3- Permission to be listed in a public student directory: ... Yes No
4- Is English your primary language: .................... Yes No
5- Attended another college: ......................... Yes No
6- Race: White Black Hispanic Asian Nat. Amer. Other
Student Signature _________________________________________________ Date ___________________________________________________________
Please Note: We cannot accept cash payments. Personal checks, bank money orders and MasterCard/Discover/Visa are acceptable.
For Mail-in and Fax-in, use MasterCard, Visa or Discover. Please complete the following:
Account No.: _____________________________________________________ Expiration Date (mo)_________ /(yr) __________
Cardholder’s Signature _____________________________________________ Print Cardholder Name ____________________________________________
Students with documented disabilities who anticipate the need for
accommodations are encouraged to visit www.northshore.edu/accessibility and follow
the outlined procedure to request accommodations at least 4-6 weeks before the start
of classes. Accessibility Services provides academic accommodations and services for
students with disabilities so as to provide equal access and opportunity to programs
and activities. For more information, please visit our website or call: Danvers Campus:
978-762-4000, x4501 or Lynn Campus: 781-593-6722, x2134.
$
Noncredit Total
Fall: 20 Winter:20 Summer:20
Month: Day: Year:
Parent/Guardian Info for Students under age 18
Last Name: Address:
First Name: City:
Home Phone: ( ) State: Zip:
Cell Phone: ( ) Email Address:
Program of Study (see list on page 2 of catalog):
34635 NSCC_WS_19_Noncredit_Text_1118 cc2018.indd 19 11/16/18 9:06 AM
