Welcome to our Quick Registration Form



This form is to be used by:

  • Students who have never attended Middlesex Community College before.
  • Students who are planning to register for any summer course, or for evening or weekend fall and spring courses.
  • Other students may call 1-800-818-3434 for registration assistance.


Follow these easy steps to register:

  1. Complete and submit the Quick Registration Form below.
  2. You will receive your MCC PIN (Personal Identification Number) which allows you to register for classes and detailed registration instructions by email within 2 business days. If you do not provide an email address, the information will be sent to your mail address.


Last First Middle
Name
Previous Name

Social Security Number: --  Male Female

Birth Date MONTH DAY YEAR
Example: 03/16/1978

Home Telephone --   Work Telephone --
Email Address

Will you need a temporary student visa (I-20) to attend Middlesex?:

Yes No

Did you earn a High School Diploma? Yes No GED? Yes No
Date of Graduation (month/year) Date of GED certificate (month/year)
Name of High School (month/year)

Choose one of the following:
I graduated from high school before the year 2003.
I earned a GED.
I completed high school in the year 2003 or later and I met MCAS requirements.
I completed high school in the year 2003 and earned a Certificate of Attainment.
I graduated in the year 2003 or later from a school that did not require MCAS (only private or non-Mass schools.)
 

Race/Ethnic Group: answer both 1 & 2 below

This information, required of educational institutions by federal or state law, will be used solely for reporting purposes. You may voluntarily provide this information.

  1. Ethnicity: Are you of Hispanic or Latino origin? Yes    No
  2. Race: Choose one or more from the list below
African American/Black  Native Hawaiian/Pacific Islander 
American Indian or Alaskan Native  White/Caucasian 
Asian 


Citizenship Birthplace
Country of Citizenship

Entrance Date:  Semester:    Year:


IN-STATE TUITION ELIGIBILITY
Street Address
City State Zip Code
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 upon request. These documents* are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for my high school diploma). The institution reserves the right to make any additional inquiries regarding the applicant?s status and to require submission 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 Information:
I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.

Applicant Name: Date
Parent/Guardian Name(Applicant is Under 18 Years Old): Date


Message

Use this space to send additional information, or send any questions you may have.


Use the following buttons to either send your application to
Middlesex Community College or to clear the information from the form.

To avoid delays in processing your MIDDLENET Quick Registration Form, make sure you have carefully completed the entire form before submitting it.


Last Modified: 7/31/13