Medical Assistant Program Application

"*" indicates required fields

Name*

First Middle Last

Former names listed on school records

(i.e. maiden name, previous married name, etc. - enter 'None' if not applicable)

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Preferred Phone*

The phone where we may contact you about your application or enrollment.

May we text you at this phone?

Are you a U.S. Citizen?*

If no, are you a permanent resident?

If you are not a legal resident, what is your current visa status?

Race/Ethnicity (Optional)

You may check as many as apply

Sex Assigned at Birth (Optional)

Emergency Contact Information

Name*

First Last Relationship

Phone*

May we text your emergency contact at this phone?

High School Last Attended

High School Info

School Name City State / Province / Region Country

Date of Graduation or Year of G.E.D./HiSET award

Have you previously attended RVCC?*

New Hampshire Residence Information

I have always lived in New Hampshire*

If No, what month and year did you move to NH?

Current state of residence if not New Hampshire

TO BE SIGNED BY ALL APPLICANTS

The information provided by the applicant on this admission application form shall be held confidential to the extent determined by Federal Law and College Policy. River Valley Community College reserves the right to deny admission to any applicant who, in the judgment of the college officials, does not qualify for admission. The College also reserves the right to require withdrawal of any student who does not satisfy the ideals of citizenship, character, or scholarship. In accordance with the terms and conditions set forth in its publications, and if accepted to abide by the rules and regulations set forth in the publications and in the Student Handbook, I also agree that the College has permissions to use any College sponsored pictures in which any likeness appears. I certify that I have read and agree with the above, and that all information provided herein is true and complete.

Signature*

Date*