RCC
Summer Learn and Earn Application
2022-23 Summer
First Name
Last Name
Suffix
Gender
Date of Birth
(mm/dd/yyy)
Social Security #
(SSN)
SASID#
(SASID- State Assigned Student Identifiers)
Please select one or more of the following that best describes you:
Are you Hispanic or Latino?
Do you reside outside of the United States?
Address Line 1
Address Line 2
City
State
Zip Code
Country
Are you a US Citizen?
Primary Phone Number
Email Address
Confirm Email Address
Please provide parent/guardian information. This information is used for emergency contact purposes.
Parent 1 First Name
Parent 1 Last Name
Parent 2 First Name
Parent 2 Last Name
Phone Number:
I/we give permission for my/our child, named above, to attend college-level classes at Roxbury Community College. I authorize Roxbury Community College to release educational records to the High School. I also understand that submission of this form RCC will be responsible for Tuition/Course fees ONLY, the student will be responsible for books.
High School:
Grade
(select one)
High School Graduation Year
For 2022-23 Summer Learn and Earn the course you will be taking is BUS 130 01, Introduction to Business.
I certify that this information is true and accurate. I understand that any misrepresentation, omission, or incorrect information shall be cause fo disciplinary action up to dismissal, with no right of appeal or to a tuition refund.
Date:
If you have completed all required questions you can click submit. If there any remaining questions to answer you can click previous.