Nicholls State University
Section 1 - Student Information (TO BE COMPLETED BY STUDENT/PARENT)
Please complete all information; incomplete applications may delay admission and registration. Please print legibly.
Semester Last Name First Name Middle Name
Gender: M F
SSN Date of birth (month, day, year) Student’s LA Secure ID Number
Address City State Zip
Home Phone Cell Phone E-mail
Emergency Contact (name, relationship, phone)
Ethnicity/Race: American Indian/Alaskan Native Asian/Pacific Islander
Caucasian (non-Hispanic)
Hispanic (Mexican-American)
Black (non-Hispanic)
Section 2 – High School Information (TO BE COMPLETED BY SCHOOL COUNSELOR)
Is the student a United States Citizen? Yes No
Has the student participated in Dual Enrollment at Nicholls State University? Yes No
Has the student participated in Dual Enrollment at another institution?
No If yes, please attach transcript.
Student’s Intended Major: _________________________________________________
Student will be taking courses (check all that apply): on the high school campus on the Nicholls campus online through Nicholls
Course information can be obtained from the Class Schedule by clicking on the Banner link at the bottom of the Nicholls homepage. Students are not allowed to
register for more than 12 hours.
Course Name
Course Number
Course Section *
Course Reference Number*
Sample: ENGL
* Required for courses taught at Nicholls campus or online through Nicholls. If students do not have a section preference, leave section blank.
Name of high school: High school ACT Code:
I hereby verify that the information above is complete and accurate.
Signature of School Counselor Date
Section 4 - Certification Information
By signing below, you certify that all information provided is correct and that you agree to the statements on this page.
I understand that as a participant in the Dual Enrollment program at Nicholls State University that I may enroll in courses at a rate established by the
I understand that I am enrolling as a Visiting/Guest Student at Nicholls State University. Upon graduation from high school, if I desire to enroll at
State University, I will apply for admission as a regular student and must meet Nicholls State University’s admission requirements.
I understand that the high school and college grades earned in those courses in which I enroll through the 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 Dual Enrollment program will be used by other
programs, including TOPS, to determine my continuing eligibility for those programs. See TOPS Q&A Q. 150-151 located in TOPS
section of
I authorize Nicholls State University, my high school, my school district, the Louisiana Board of Regents, the Louisiana Department
of Education, and the Louisiana Office of Student Financial Assistance access to my high school and college academic record. I
further authorize my high school and Nicholls State University to exchange my academic information (i.e. transcript) for any
purpose related to my eligibility or participation in this program.
I acknowledge that (1) I am enrolling in the course(s) listed in this application; (2) it is my responsibility to OFFICIALLY WITHDRAW or DROP a
class I decide not to complete by Nicholls State University’s 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 may not be eligible to enroll as an Dual Enrollment student in a future semesters.
Nicholls State University Assumption of Risk, Release and Liability Waiver Form for Enrollment of Minor Students
(“the minor student”) and (“the parent” or “the
legal guardian”) want the min
student to take classes at Nicholls State University. The parent represents that the minor student is not yet 18
years of age; that the parent is the parent or legal guardian of the minor student; and that the parent is legally competent to sign this form on
behalf of the minor student. The parent and minor student (collectively “we”) agree to the following
representations, understandings
We understand that the law and culture of higher education generally presume that college students are mature adults capable of independently
evaluating their environment and
attending to their needs. We understand that the minor student will voluntarily enter into an adult
that Nicholls State University will treat the minor student as an adult within that environment; and that the minor student accepts
fully the rights and responsibilities of an adult within that environment. We understand that expectations that we may have for support and
service(s) that may arise from the minor student’s experience in
secondary education will often not be appropriate or available in the collegiate
setting. In particular, we understand that the minor student will be taking college level courses and that the academic environment will encourage
free discussion and open inquiry of sometimes controversial subjects.
We represent that the minor student has the emotional and intellectual maturity necessary to participate beneficially in the collegiate
environment. We have access to, and agree to follow, all Nicholls State University policies and procedures and, if the minor student indicates
that he or she cannot adapt to that environment, we agree to withdraw, and/or permit Nicholls State University to remove, the minor student from
Nicholls State University.
We understand that Nicholls State University will have specific rules that will apply to the minor student’s ability to enroll and attend. These rules
may include, but are not limited to, certain enrollment prerequisites, registration requirements, placement tests, and matriculation status. For a
complete understanding of like
applicable rules,
we agree to consult with Nicholls State University and we agree to accept their application to the
minor student.
On behalf of ourselves, our family, heirs and personal
we understand and agree that Nicholls State University will treat the
minor student as an adult; that we have had a reasonable opportunity to consider the risks of a minor student participating in the adult and
learning environment of Nicholls State University; and that we assume all such risks regarding the minor student’s participation at
Nicholls State University. On like behalf, we further release, hold harmless, indemnify and covenant not to sue the University of Louisiana
System, Nicholls State University, and their governing boards, trustees, employees and any agents from and against an
y and all liability for harm,
injury, damage, claims, demands, actions, causes of action and expenses of any kind that we may have or that may hereafter accrue to us, directly
or indirectly, related to any loss, damage or injury that we may sustain from the minor student’s participation at Nicholls State University.
We have both read this form; we both understand its terms and conditions; and we both intend to be bound by it from the date of signature
below until the student reaches his or her 18th birthday and are no longer a minor.
Student Signature Date
Parent Signature Date
Section 5 - Criteria for Dual Enrollment Eligibility
To be eligible for participation in the Dual Enrollment program at Nicholls State University students must:
be at least 15 years of
age by the start of the semester of enrollment.
be enrolled in grades 11
or 12
have ACT or SAT scores. ACT or SAT scores will be used for admission and placement.
Only students
who have not taken ACT or SAT after ninth grade may use ASPIRE, MAP, Pre-ACT, Pre-SAT, or EOC
have a minimum ACT composite score of
19 or SAT total score of 1010.
(For students without ACT/SAT scores: ASPIRE composite score of 430, MAP language + math score of
490, Pre-ACT composite score of 19, or Pre-SAT total score of 1010.)
have a minimum ACT English score of 18, SAT ERW score of 500, or ACCUPLACER Writing score
(For students without ACT/SAT scores: ASPIRE English score of 433, MAP Language score of 245, Pre-
ACT English score of 18, Pre-SAT ERW score of 500, EOC English II score of 740, or LEAP 2025
English II Mastery of above.)
have a minimum ACT math score of 19, SAT math score of 510, or ACCUPLACER QRAS score of
(For students without ACT/SAT scores: ASPIRE math score of 431, MAP math score of 265, Pre-ACT
math score of 19, Pre-SAT math score of 510, EOC Algebra I score of 760, EOC Geometry score of 750,
or LEAP 2025 Geometry Mastery or above).
have a minimum high school GPA of
1. For College Algebra (MATH 101) eligibility, students must have a minimum ACT math score of 21 or SAT math
score of 530, or an ACCUPLACER QRAS score of 263. (For students without ACT or SAT scores: ASPIRE math
score of 435, Pre-ACT score of 22, EOC Algebra I score of 770, EOC Geometry score of 760, or LEAP 2025 Geometry
Master or above and completion of Algebra II with a C or better.)
2. Students who do not meet minimum placement requirements for either English (ACT English sub-score of 18) or
mathematics (ACT math sub-score of 19) will be considered for enrollment on a case-by-case basis. Students admitted
under these circumstances may enroll in courses at Nicholls on a limited basis depending on the area of deficiency and
must be addressing the area of deficiency. By the spring of his or her senior year, a student must meet English,
mathematics, and composite score requirements to participate in Dual Enrollment.
School counselors, students, and parents should refer to the Dual Enrollment website at https
center/dual-enrollment/ for a listing of important dates and other information. Contact the Academic Services Center at 985-448-4117
or e-mail with questions.