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MCLA

Dual Enrollment Application for Spring 2022

***Name***
First:		Middle:		Last:

***Address/Contact Information***
Street1:
Street2:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Confirm Email:

***Personal Information***
Date of Birth (MM/DD/YYYY):
Social Security Number:
Citizenship Status:
Gender:	Male Female No Response
Ethnicity:	Hispanic or Latino Not Hispanic or Latino
Race	American Indian or Alaskan Native Asian Black or African American
	Native Hawaiian and Other Pacific Islander White Cape Verdean

***Additional Information***
Are you currently a full-time resident of Massachusetts?	Yes No
Please enter your Massachusetts State Assigned Student Identifier (SASID).
Have you ever taken classes at MCLA?	Yes No
Please enter your current high school name
Please enter your current guidance counselor's name
Please select your Dual Enrollment class
Have you ever been placed on disciplinary/academic probation, suspension or dismissal from high/school or college?	Yes No
Have you been adjudged a youthful offender or been convicted of a felony?	Yes No

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