Dual Enrollment Book Voucher for Home Education Students
Instructions: This Voucher must be completed by the Home Education Student. The Home Education Parent will
complete the course information and return the Voucher to the student for
submission to the campus bookstore to
obtain course materials.
Campus (separate voucher required for each campus enrolled)
Student’s Personal Information
Student’s Last Name First Name
Middle
PBSC Student ID
Student’s Birth Date (MM/DD/YYYY) Home Phone # Cellular Phone # Email Address
Student’s and Parent’s Certification
By signing below, the student and the student’s parent/guardian certify the following: (1) When available, students will
be given a used or rental textbook; (2) Students are responsible for returning all rental textbooks issued during each
semester of study to the campus bookstore; and (3) Students will be held financially responsible for any rental textbook
(s) not returned. Students will be blocked from future registration as well as transcripts until books are returned or
financial obligation met.
Student’s Full Name (print legibly) Student’s Signature Date (MM/DD/YYYY)
Parent’s/Legal Guardian’s Name (print legibly) Parent’s/Legal Guardian’s Signature Date (MM/DD/YYYY)
Signature of Enrollment Representative – PBSC Print Name Date (MM/DD/YYYY)
(Verify Legal Compliance & Eligibility Form processed)
Textbook Information
To be completed by Home Education Parent
To be completed by Bookstore representative
TOTAL: $
Signature of Bookstore Representative Date (MM/DD/YYYY)
Bookstore – White Palm Beach State College – Scan to record
click to sign
signature
click to edit
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click to sign
signature
click to edit
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