Medical Assistant Program Application

"*" indicates required fields

(i.e. maiden name, previous married name, etc. - enter 'None' if not applicable)
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Mailing Address (if different from above)
The phone where we may contact you about your application or enrollment.
You may check as many as apply

Emergency Contact Information


High School Last Attended

High School Info

New Hampshire Residence Information


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.
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