1 College Place – Claremont, NH 03743-9707 ● with Academic Centers in Keene, NH & Lebanon, NH
www.rivervalley.edu ● Submit Form to: RVCCRegistrar@ccsnh.edu
REGISTRATION FORM
SEMESTER:___________, YEAR:_______
(Complete all items. Please print clearly and sign electronically or in ink at bottom)
A ___ ___ ___ ___ ___ ___ ___ ___ _________________________________, ________________________, ___________
Student ID# Last Name First Name Middle Initial
Program Major: ____________________________________ E-Mail Address: ______________________________________________
Mailing Address: ____________________________________ City: ________________________ State: _______ Zip: ___________
Physical Address: ____________________________________City: ________________________ State: _______ Zip: ___________
Home Phone: (__ __ __) __ __ __ - __ __ __ __ Cell Phone: (__ __ __) __ __ __ - __ __ __ __
*Social Security #: ___ ___ ___ - ___ ___ - ___ ___ ___ ___(required) Check here if this is a change in address, phone, or e-mail.
* Federal law requires that RVCC collect names and corresponding social security numbers for all students attending the college. The college is required by the Internal Revenue Code to produce a
1098-T tax form (26 U.S.C.A. Section 6050 or Federal Register, Vol. 67, No. 2244, page 777686 (ii)) which requires the college to report the names and social security numbers of all students taking
credit-bearing courses. Please note, however, that the college will ensure 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.
TOTAL CREDITS: _________
This is an opportunity to list a second choice if, at the time your registration is entered, your first choice above is full and you would otherwise be placed on a waitlist.
1
st
CHOICE CRN#
FROM ABOVE
Before you submit this form, please read the following notice: I certify that I reside at the address provided above. I have met any prerequisite and/or corequisite courses that may be required for any
of the above courses. (Attach transcript or grade report if prerequisite/corequisite courses were taken off-campus.) (See back of this form if registration waivers are necessary.) I accept responsibility
for the selection of and payment for the courses as indicated above. I have read and understand the Refund/Withdrawal Policy. NOTE: I understand that I must fulfill my financial obligation
two weeks before the start of the semester, or my registration will be voided and my classes deleted. (See payment options below.) 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. (Effective 4-1-14)
For courses with a duration of more than 2-weeks and less than 15-weeks I understand that I have
one week from the first day of the course’s term to receive a full refund by submitting a drop form or dropping via SIS.
___________________________________________________________ ____________________________________________________________
Student Signature & Date (REQUIRED) Advisor Signature & Date (REQUIRED)
(Parent/guardian must sign & date, too, if under 18) ______________________
METHOD OF PAYMENT
Cash Check or Money Order Attached (Payable to “CCSNH”) Financial Aid Award Letter Received
Nelnet Online Payment Plan (e-cashier) Company or Third Party Agency Billing (Attach authorization letter)
You can pay with a Visa, MasterCard or Discover Card via your SIS account which you can access through www.rivervalley.edu. You may also call the Business Office at 603-542-7744; x5302 or x5304.
Tuition and fees are due two weeks before the first day of the semester. RVCC does not send paper bills or schedules. Upon registration, you are enrolled unless
otherwise notified. No confirmation will be mailed. Classes are subject to change. Students should review their account in the Student Information System (SIS) for
their e-bills, classroom location(s), schedule, grades, financial aid information, student email accounts, etc.
Federal Governmental Statistical Information (Optional): Sex: F M Have you ever served in the military? Yes No
Ethnic Background: Hispanic or Latino Not Hispanic or Latino US Citizen: Yes No Date of Birth: ________________
Select one or more races: American Indian/Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
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