DUAL ENROLLMENT
AUTHORIZATION FORM
Student is required to complete this section:
Name ______________________________________
Date of Birth ______ / _______ / ___________
Social Security # ______________________________
(Required in order to receive Dual Enrollment Grant payment)
Phone (___________) __________________________
High School ___________________________________
Fall Spring Summer
Registration for:
(select one)
(Aug - Dec) (Jan - May) (May - Aug)
Year ______________________
Course(s) in which I would like to enroll:
Course ____________________________________
(subject, course, section)
On-Ground Online
Days/Time _________________
Course ____________________________________
(subject, course, section)
On-Ground Online
Days/Time _________________
Course ____________________________________
(subject, course, section)
On-Ground Online
Days/Time _________________
I authorize East Tennessee State University to release my transcript of academic work
to my high school, after attending East Tennessee State University as a Dual Enrolled
student. I understand this permission form only applies while attending East Tennessee
State University under the status of Dual Enrollment or Early Admission. I understand the
guidelines concerning my admission and the registration regulations. I understand I must
complete the application on-line to be considered for the Dual Enrollment Grant and ETSU
Dual Enrollment Scholarship or I will be responsible for all tuition and fees due. I provide
consent for information regarding my admission and records to be discussed with my
parent and/or guardian while enrolled as a dual enrollment student. I understand that
receiving more than $1,200 in Dual Enrollment Grant funding in high school will result in a
(dollar for dollar) reduction in my Hope Scholarship during my rst semester of enrollment
at the postsecondary level. I understand I will be subject to the university’s regular
established policies for registration and grading.
Student Signature
Date
No Application Fee
One of the benefits of dual enrollment at ETSU is that the
application fee is waived. This benefit continues for dual
enrollment students who later wish to apply for freshman
admission to ETSU: their application fee will be waived again.
Refund Policy
East Tennessee State University adheres to The Tennessee Board of
Regents (TBR) system-wide policy for calculating fee adjustments
and refunds. The fee adjustment policy provides for three fee
adjustment periods and is based entirely upon the ofcial date of
withdrawal or change of course which would result in a recalculation
of fees. Students who need to drop any courses or withdraw from
the University should do so before the start of classes for the term to
ensure that no registration fees are owed.
Please visit etsu.edu/bf/bursar/tuitioninfo/calendar.php for specic
refund/adjustment periods for each part-of-term.
School Recommendation
Guidance Counselor or Principal is required to complete this section:
This student meets the established admission guidelines and has my
permission and recommendation to enroll at East Tennessee State
University.
This student has a current grade point average of _______.
Principal or Guidance Counselor Signature
Date
Permission to Enroll
Parent/Guardian is required to complete this section:
My son or daughter has my permission to enroll at East Tennessee
State University as a special student. I understand the guidelines
concerning his/her admission and the regulations regarding
registration for classes. I understand that receiving more than $1,200
in Dual Enrollment Grant funding in high school will result in a (dollar
for dollar) reduction in my son or daughter’s Hope Scholarship
during their rst semester of enrollment at the postsecondary level. I
understand that my son/daughter is subject to the university’s regular
established policies for registration and grading. If my son or daughter
is participating in dual enrollment with two institutions, I authorize
the two institutions to exchange information concerning the dual
enrollment grant and the academic record.
Parent/Guardian Signature
Date
Parent e-mail address
click to sign
signature
click to edit
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