Spring 2013 - Massasoit Community College

MASSASOIT COMMUNITY COLLEGEMASSACHUSETTS COMMUNITY COLLEGES - IN-STATE TUITION ELIGIBILITY FORMLast Name______________________________________________First Name_________________________________MI________Street Address_______________________________City_________________________State_____________Zip Code____________SSN# or Student I.D. Number_____________________________________________________Date of Birth____________________Are you a U.S. Citizen?___________Yes___________No. If not, please complete the following:Are you a Permanent Resident?______Yes _________No (If yes, list alien registration number:______________________________)If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail:_________________________Please check the in-state or reduced tuition eligibility category that applies to you:_____I have been a Massachusetts resident for six (6) continuous months and intend to remain here.As proof of my intent to remain in Massachusetts, I possess at least 2 of the following documents, which I shall present to the institution uponrequest. These documents* are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possiblyfor my high school diploma). The institution reserves the right to make any additional inquiries regarding the applicant’s status and to requiresubmission of any additional documentation it deems necessary.Please check-off those documents you possess as proof of your intent to remain in Massachusetts._____Valid Driver’s license _____Utility bills* _____Employment pay stub*_____Valid Car registration _____Voter registration* _____State/Federal tax returns*_____Mass. High School Diploma _____Signed lease or rent receipt* _____Military home of record*_____Record of parents’ residency for unemancipated person*_____Other________________________I am an eligible participant in the New England Board of Higher Education’s Regional Student Program._____I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts.Certification of InformationI certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shallbe cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.Applicant Signature:__________________________________________________________________________Date:_____________Parent/Guardian Signature (Applicant is Under 18 Years Old):_________________________________________Date:_____________FOR OFFICIAL USE ONLY - DO NOT WRITE IN THIS BOXI have reviewed the above information in order to determine this individual’s eligibility to receive the in-state tuition rate. Based on my review I have determinedthat this individual:_____IS eligible for the in-state tuition rate._____IS NOT eligible for the in-state tuition rate._____I am unable to make a determination at this time. The following additional information has been requested from the applicant:_________________________________________________________________________________________Authorized College Personnel:_________________________________________________________Date:____________PRIVACY STATEMENTBy completing the registration form, I understand that the information will be held in confidence and Massasoit Community College will only disclose informationto authorized school officials who act in the student’s educational interest within the limitations of their “need to know” and to authorized government entities.Massasoit Community College strictly adheres to FERPA (Family Rights and Privacy Act of 1974) (http://www.massasoit.mass.edu//misc/ferpa.cfm) which setsforth requirements regarding the privacy of student records. Any inquiries or concerns regarding the methods of holding data and types of data to be held maybe addressed to the Vice President of Enrollment Management.NOTICE OF NON-DISCRIMINATIONMassasoit Community College is an affirmative action/equal opportunity employer and does not discriminate on basis of race, creed, religion, color, gender, sexualorientation, age, disability, genetic information, maternity leave, and national origin in its education programs or employment pursuant to Massachusetts GeneralLaws, Chapter 151B and 151C, Title VI, Civil Rights Act of 1964; Title IX, Education Amendments of 1972; Section 504, Rehabilitation Act of 1973; Americans with DisabilitiesAct, and regulations promulgated thereunder, 34 C.F.R. Part 100 (Title VI), Part 106 (Title IX) and Part 104 (Section 504). All inquiries concerning application ofthe above should be directed to the College’s Affirmative Action Officer and/or the College’s Coordinator of Title IX and Section 504. Executive Director of InstitutionalDiversity, Joyce Zymaris at 508-588-9100 x1304. Brockton Campus, Room A234.CORI/SORIStudents interested in participating in an Academic or Non-credit program that involves working with children, the disabled, or vulnerable populatons including aclinical affiliation with a private and/or public health care provider, may be required to undergo Criminal Offender Record Information (CORI) and/or a Sex OffenderRecord Information (SORI) checks. Unsatisfactory CORI status will prohibit participation in Clinical/Internship experiences. CORI checks may be performed pursuantto Massachusetts General Law, Chapter 6, Sections 167-178B, and consistent with guidelines promulgated by the Commonwealth of Massachusetts Departmentof Public Health. SORI checks may be performed pursuant to Massachusetts General Law, Chapter 6, Sections 178C.