Enrollment Form This form must be returned to the Office of Admissions by May 1, 2011.
To confirm your place, you must submit this form with your deposit of $500 ($300 for commuter students) to the Office of Admissions, postmarked no later than May 1. Please make checks payable to Emmanuel College. NAME
SOCIAL SECURITY NUMBER (IF APPLICABLE)
STREET ADDRESS
CITY
STATE
TELEPHONE NUMBER
ZIP CODE
COUNTRY
E-MAIL ADDRESS
Enrollment Decision — Please select (❑) one of the following options and sign: ❑ Enrolling as a Resident Student ($500 Deposit Required)
I will attend Emmanuel College and wish to make a reservation for a residence hall. To confirm this reservation, I am enclosing payment in the amount of $500 ($300 for tuition and $200 for room and board). I understand that this fee is non-refundable after May 1, 2011, and will be applied to my first year’s charges.
❑ Enrolling as a Commuter Student ($300 Deposit Required)
I will attend Emmanuel College as a commuter student and am enclosing payment in the amount of $300 to hold my space in the class. No space will be reserved for me in Emmanuel’s residence halls. I understand that this fee is non-refundable after May 1, 2011, and will be applied to my first year’s charges.
❑ Not Enrolling
I will not be attending Emmanuel College. I have instead decided:
❑ to attend
.
STUDENT SIGNATURE
❑ not to attend college at this time. DATE
Payment Method — Please select (❑ ) one of the following options: ❑ Check or Money Order is enclosed, made payable to Emmanuel College.
❑ Wire Transfer has been initiated. (Please call our office at 617.735.9715 for instructions.) ❑ Credit Card (MasterCard, Visa, Discover or American Express) ❑ I called the Admissions Office and made a credit card payment by phone on ______ /______ /______. ❑ I hereby authorize payment from the following account in the amount indicated above. Card Type (check one):
❑ ❑ ❑ ❑
Card Number:
Expiration Date:
Cardholder:
Security Code:
MasterCard Visa
(as printed on card)
Discover
Cardholder Signature:
Date:
American Express Student Name:
Please print, sign and return to The Office of Admissions Please fill out reverse side Office of Admissions, Emmanuel College, 400 The Fenway, Boston, MA 02115
Enrollment Form continued
Please provide parent/guardian information. The College will be communicating with your parent/guardian throughout your academic experience. The following information will be used for such communication.
Parent 1/Guardian 1
Parent 2/Guardian 2
Relationship to Student _______________________________
Relationship to Student _______________________________
❑ Dr.
❑ Dr.
❑ Mr.
❑ Mrs. ❑ Ms.
❑ Mr.
❑ Mrs. ❑ Ms.
First Name ________________________________________
First Name ________________________________________
Last Name ________________________________________
Last Name ________________________________________
Street Address (if different from student) ____________________________________________________
Street Address (if different from student) ____________________________________________________
City ________________________________________________
City ________________________________________________
State ________ Zip ___________ Country ________________
State ________ Zip ___________ Country ________________
Home Telephone Number _____________________________
Home Telephone Number _____________________________
Cell Phone __________________________________________
Cell Phone __________________________________________
E-mail ______________________________________________
E-mail ______________________________________________
Name of Employer ___________________________________
Name of Employer ___________________________________
Job Title ____________________________________________
Job Title ____________________________________________
College(s) Attended __________________________________
College(s) Attended __________________________________
Degree(s) and Year of Graduation ____________________________________________________
Degree(s) and Year of Graduation ____________________________________________________
Please list any family members who have attended Emmanuel College. Name
Year of Graduation
Degree or Certificate
Relationship to You
_____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
Please sign and return this form with payment to the address below. The full deposit is due by May 1, 2011, regardless of any scholarships or financial aid awarded. Contact the Office of Admissions at 617.735.9715 or enroll@emmanuel.edu with any questions.
Please print, sign and return to The Office of Admissions
Office of Admissions, Emmanuel College, 400 The Fenway, Boston, MA 02115
EC3