Fillable Non- Credit Registration Form 200701LS Editable PDF (Roxbury Community College)

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Non- Credit Registration Form 200701LS Editable PDF (Roxbury Community College)

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File type: PDF

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Refund Policy: To be eligible to request a refund, you must submit a request in writing by the following deadlines:
Certificate Trainings & Professional Education Programs: Before the start of the second (2nd) class).
ESOL, HiSET, and other Lifelong Learning Programs: At least one (1) business day before the first (1st) class.
Center for Workforce Development
Building #4, Room 102
Business Office: Academic Building #3, Room 125
STUDENT INFORMATION (Please print clearly) FY’20_____ □ Fall □ Spring □ Summer
Last Name: ____________________________________ First Name: ________________________________
Address: _________________________________________________________________________________
City: __________________________________________ State: __________ Zip: ____________________
Phone: _______________________________________ Gender: □ Female □ Male
Email: ________________________________________ Date of Birth: ______________________________
Demographic Information Educational Information
1. Please select the race(s) you identify as: Do you have:
□ American Indian or Alaska Native □ High School Diploma □ GED/HiSET
□ Asian □ Black or African American □ Currently pursuing GED/HiSET □ Don’t have
□ Native Hawaiian or other Pacific Islander Have you attended RCC before? □ Yes □ No
□ White Are you an RCC Degree Candidate? □ Yes □ No
3. Are you Hispanic or Latino? □ Yes □ No Student is Child Under Age 18 □ Yes*
4. Are you Cape Verdean? □ Yes □ No *Must complete Photo Release/Liability Waiver
4. Country of Citizenship: _________________________
5. If you are not a US citizen, do you have Permanent Resident Status (green card)? □ Yes □ No
COURSE REGISTRATION
COURSE CODE
COURSE NAME
DAY
TIME
TUITION
End
CSA
CSA
CSA
CSA
STUDENT ID #:
TOTAL AMOUNT TO BE PAID:
NON-CREDIT REGISTRATION FORM
I hereby register for the above course(s) and assume full responsibility for the accuracy of the information above.
Student’s Signature: ________________________________________ Date: ___________________
Payment Method: □ Credit/Debit Card □ Check □ Money Order
RCC Staff Signature: _______________________________________ Date: ___________________
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20-21
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Non- Credit Registration Form 200701LS Editable PDF (Roxbury Community College)

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Completed 17 September 2020

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