High School Counselor/Representative Signature Date
Student signature Date
Parent Signature Date
Dual Credit Student Registration Form
Semester for Enrollment:
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
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
I must view and accept the University of Texas at Tyler Financial Responsibility Agreement each semester in order to be
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
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
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