_____________________________________________________
High School Counselor/Representative Signature Date
_________________________________________________________
Student signature Date
_________________________________________________________
Parent Signature Date
Dual Credit Student Registration Form
Semester for Enrollment:
Spring
Fall
YEAR: ________
_________________________________________ _______________ __________________
First Name Middle Initial High School
_____________________________________________
Email Address
__________________
Grade Level
________________________________________
Last Name
___________________________________
UT Tyler Student ID
________________________________________
Intended Major
I understand:
• Dual Credit student records are governed by the Family Educational Rights and Privacy Act (FERPA), which states the student
owns his/her educational record from the first semester of enrollment, regardless of age.
• Student’s signature permits UT Tyler to disclose mid-term and final grades in addition to general admission information to the
high school, parents, and/or legal guardians.
• The student will be enrolling in college credit course(s) and a letter grade will be recorded on his/her permanent college
transcript.
• All registration deadlines, including adding, dropping, and withdrawing from coursework follow the official University of Texas at
Tyler Academic Calendar.
• All payment deadlines and refund schedules follow the official University of Texas at Tyler Academic Calendar and Refund
Schedule.
• I must view and accept the University of Texas at Tyler Financial Responsibility Agreement each semester in order to be
enrolled.
• I must meet official TSI requirements and course prerequisites in order to be enrolled.
• I assume ALL responsibility for successfully completing my coursework, including directly working/communicating with my
instructors and The University of Texas at Tyler regarding grades, attendance, and/or behavioral issues.
• The University of Texas at Tyler assumes no responsibility if I lose eligibility to participate in the National Collegiate Athletic
Association (NCAA) or any other collegiate level activities.
• I am responsible for dropping or withdrawing. I understand that I must talk with my counselor and then submit required Add/Drop
or Withdrawal Form to the Dual Credit Coordinator.
Office Use Only
Course Title Course Number Section Number
Class Number
TSI ASSESSMENT
Writing____________ Minimum 340/4 Essay or 310-339/5 Essay
Math _____________ Minimum score 350- Required for any MATH
Reading ___________ Minimum score 351- Required for all other college courses
EOC______________ ACT________________
SAT______________ PSAT______________
Officially Registered
Date:___________
By:____________
By signing this form I confirm that I have read and understood the above-listed responsibilities and give consent to enroll in dual credit courses.
______________________________
Dual Credit Coordinator Signature
