RUNNING START REGISTRATION FORM

RUNNING START
REGISTRATION FORM
Manchester Community College (MCC)
1066 Front Street
Manchester, NH 03102
________________________
* Social Security Number
_______________________________________________________________________
Last Name
First Name
Middle Initial
*Federal law requires that MCC collect names and corresponding social security numbers for all students taking a college course. The
college is required by the internal Revenue Code to produce a 1098-T tax form (26 U.S.C.A. Section 6050S 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. 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, regulations or applicable policies.
Mailing Address
City
Home Phone #
Date of Birth:
State
Cell Phone #
/
/
Sex:
M
Zip Code
E-Mail Address
F
Status:
Junior
Senior
Exception (college approval)
Ethnic Background (Optional – for Federal Government Statistics Only):
African American
CRN#
------
American Indian/Alaskan
COURSE # & SECTION
High School:
Asian/Pacific Isle
Hispanic
COLLEGE COURSE TITLE
White
CREDITS
Other
TUITION
$150.00
Teacher’s Name:
Teacher’s Signature:
Disabilities Services: Please be advised that students currently receiving modifications in an IEP under the Individuals with Disabilities
Education Act and Section 504 of the Rehabilitation Act will not be eligible for modifications in a college course in the Running Start
program. While students may be eligible for accommodations through the college’s Disabilities Services Office, students must be otherwise
qualified to do college level work and address the essential elements of the course without fundamental alterations to the curriculum. If you
have questions, please contact the Disabilities Coordinator at the college offering the course in the Running Start program.
Financial Obligation: 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 understand that registration fees are nonrefundable and 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.
Student Signature
Date
Parent/Guardian Signature
(Required if student is under 18 years of age)
Date
PAYMENT INFORMATION
(Payment due at time of registration – Make checks payable to MCC)
Check / Money Order (Attach)
School District (Attach Authorization)
Scholarship (Attach Application)
Voucher (Attach)
Registration Form Must be Returned With Payment by_______________________