Application for Admission
RPCC Dual Enrollment
River Parishes Community College
Biographical Information
LA Secure ID:
Social Security Number:
Date of Birth (mm/dd/yy):
/ /
Semester & Year of Enrollment: Fall (August) Spring (January) Current School Year: 20______ - 20______
Is this your first semester participating in
RPCC dual enrollment?
YES
NO
Last Name:
Middle:
Mailing Address:
City:
State:
Zip:
Parish or County:
Phone:
(H)
(W)
Email Address:
Ethnic Origin
: Are you Hispanic/Latino? Yes No (If no, check one or more of the following)
White Asian American Indian or Alaska Native Race and ethnicity unknown
Black/African American Native Hawaiian or Other Pacific Islander Two or more races Nonresident Alien
Gender: Male
Female
Are you a citizen of the United States?
YES NO
Educational Information
High School:
ACT HS Code: _____________
Grade Level:
9
th
10
th
11
th
12
th
Number of Carnegie units completed:
____________________
Career Area of Concentration:
(for work skills courses ONLY)
______________________
Student is on track for completing the required high school core curriculum: YES NO
A copy of this student’s PLAN, ACT or SAT scores is attached YES NO
Student previously participated in the Dual Enrollment Program YES NO
Student earned a grade of _________ in the last college course in which s/he was enrolled for participation in the dual
enrollment program as evidenced by the attached college transcript/grade report.
Enrollment Information
Course Dept &
Course Number
CRN
Course
Section
Course Title
College
Credits
HS LDE
Number
Payment Type
TOPS
Tech
MOU
Student
Payment
First Name:
Emergency Contact Information
Full Name:
Relationship:
Address:
City:
St:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Certification & Agreement of Dual Enrollment Program
*** Please read all statements thoroughly before signing ***
To be completed by high school student:
I certify that all information I have provided in this application is correct.
I have received a copy of the TOPS Tech Early Start Program Eligibility Criteria Framework.
If I am approved for participation in the TOPS Tech Early Start Program, I will comply with all the requirements.
I understand that I am enrolling as a Visiting/Guest Student at the college/university. Upon graduation from high school, if I desire to enroll
at a college or university, I will apply for admission as a regular student and must meet the college/university admission requirements.
I understand that the college courses and high school and college grades earned in those courses in which I enroll through the RPCC Dual
Enrollment Program will be on my permanent high school and college academic records
I understand that the grades I earn on college courses in which I enroll through the program will be used by other programs, including
TOPS, to determine my continuing eligibility for those programs. See TOPS Q&A 150-151 located in TOPS section of www.osfa.la.gov
I do hereby authorize the Board of Regents and the Office of Student Financial Assistance access to my high school and college academic
records.
I acknowledge that: (1) I am enrolling in the course listed above; (2) it is my responsibility to OFFICIALLY WITHDRAW or DROP a class I
decide not to complete by the college/university published deadline; and (3) if I withdraw from the college course or earn a college grade
other than A, B, C, or P in the course, I will not be eligible to enroll into the program the following semester.
Signature of
Applicant:
Date:
To be completed by parent/guardian:
I certify that all information I have provided in this application is correct.
I have received a copy of the TOPS Tech Early Start Program Eligibility Criteria Framework.
If I my child is approved for participation in the TOPS Tech Early Start Program, he/she will comply with all the requirements.
I understand that my child is enrolling as a Visiting/Guest Student at the college/university. Upon graduation from high school, if my child
desires to enroll at a college or university, he/she will apply for admission as a regular student and must meet the college/university
admission requirements.
I understand that the college courses and high school and college grades earned in those courses in which he/she enrolls through the
RPCC Dual Enrollment Program will be on his/her permanent high school and college academic records
I understand that the college courses in which he/she enrolls through the program will be used by other programs, including TOPS, to
determine my continuing eligibility for those programs. See TOPS Q&A 150-151 located in TOPS section of www.osfa.la.gov
I do hereby authorize the Board of Regents and the Office of Student Financial Assistance access to my child’s high school and college
academic records.
I acknowledge that: (1) my child is enrolling in the course listed above; (2) it is my child’s responsibility to OFFICIALLY WITHDRAW or
DROP a class I decide not to complete by the college/university published deadline; and (3) if I withdraw from the college course or earn a
college grade other than A, B, C, or P in the course, I will not be eligible to enroll into the program the following semester.
Signature of
Parent /
Guardian:
Date:
To be completed by high school counselor or principal:
I certify that the student completing this application has permission to participate in the RPCC Dual Enrollment Program.
I certify that the information provided for this student by the high school is correct.
Signature of
High School
Official:
Date:
River Parishes Community College operates in compliance with Title VI of the Civil Rights Act of 1964, Title IX, of the 1962 Educational Amendments and Section 504 of the Rehabilitation Act of 1973. The College does not discriminate on the
basis of race, color, religion, sex, national origin, age, disability, marital status, or veteran status. The College is also in compliance with the Family Rights and Privacy Act of 1974 (P.L. 93-380) as amended by the (P.L. 95-568).
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