Fillable Eastern Wyoming College Concurrent Dual Jumpstart Registration Form

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Eastern Wyoming College Concurrent Dual Jumpstart Registration Form

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The Eastern Wyoming College Concurrent Dual Jumpstart Registration Form form is 2 pages long and contains:

  • 4 signatures
  • 48 check-boxes
  • 92 other fields

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File type: PDF

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EWC ID# Fall Spring Year WISER ID #
Legal Name (Please Print)
Please Check:Male Female
Last First Middle
E-mail address: Cell Number
Social Security Number Date of Birth Phone Number
Permanent Mailing Address
Street
High School
City
Grade Level (please check)
State Zip
Expected High School Graduation Year
The U.S. Department of Educaon requests that colleges and universies receiving nancial assistance submit enrollment data for certain ethnic groups. Individual students
will not be idened in any reports.
Are you Hispanic or Lano? Yes No
Mark all that apply of the following:
American Indian or Alaska Nave Asian Black or African American Nave Hawaiian or Pacic Islander White
I live in: Goshen County, WY Converse County, WY Crook County, WY Niobrara County, WY Plae County, WY
Weston County, WY WY not EWC Service Area Counes Out-Of-State Not listed above
Are you a U.S. Cizen or Permanent Resident? Yes No If no, what is your country or cizenship? ________________________
Do either of your parents have a four-year baccalaureate (bachelor’s) degree? Yes No
Oce Use: U/R_____
U_____
F___
__
Eastern Wyoming College – Concurrent, Dual, & Jumpstart Registraon
Eastern Wyoming College is dedicated to providing opportunies and recognizing the talent of all people within this instuon. There is commitment to a policy of equal opportunity for all persons on the basis of merit
without regard to race, color, naonal origin, marital status, age, sexual orientaon, gender, religion, polical belief, veteran status or disability. In accordance with the policy, EWC arms its commitment to non-discriminaon
in its employment, admission or access to programs and acvies, treatment of any person, as they relate to recruitment, hiring, selecon, screening, tesng, compensaon, promoon, employment benets, educaonal
opportunies, access to programs, work assignments, applicaon of discipline, access to grievance procedures, and any and all other condions which are provided by Eastern Wyoming College policy, regulaon, rule or
pracce. Inquiries concerning Title II, Title VI, Title VII and Secon 504 may be directed to Edward Meyer, Director of Human Resources, 307-532.8330. Title IX inquiries may be directed to Dr. Rex Cogdill, Vice President for
Student Services, 307.532.8257. Both may be contacted at Eastern Wyoming College, 3200 West C. Street, Torrington, WY 82240. Alternavely you may contact the Wyoming Department of Educaon, Oce for Civil Rights
Coordinator, 2nd Floor, Hathaway Building, Cheyenne, WY 82002-0050, or 307.777.7675.
Agreement of Pares
STUDENT AND PARENTS OR GUARDIANS: Endorsement of the form by the STUDENT and PARENT, unless the STUDENT is 18 years old, shall be evidence that he/she possess
an awareness of, and agree with the following provisions:
1. Admission and Enrollment of Students
For a student to be accepted and enrolled into a dual, concurrent or jumpstart credit program, the STUDENT shall:
a) discuss potenal college credit courses with the appropriate DISTRICT and POSTSECONDARY INSTITUTION sta, including POSTSECONDARY INSTITUTION
admission and registraon requirements, course requirements, credits to be aempted, credits to be awarded, scheduling under dual credit, jumpstart
implicaons for failure to successfully complete the course;
b) obtain course requirements for each course, including course prerequisites, course content, grading policy, aendance requirements, course compleon
requirements, performance standards, and other related course informaon (course syllabus)
c) obtain approval for enrolling in the dual, concurrent or jumpstart credit program each semester by acquiring all necessary signatures on the forms;
d) register for courses during the POSTSECONDARY INSTITUTION standard registraon periods (2 weeks aer start of high school semesters)
(Note: enrollments shall not be permied aer the close of posted late registraon)
e) discuss any request for a change in registraon (add, drop, withdrawal) and complete all necessary forms and procedures with appropriate DISTRICT
and POSTSECONDARY INSTITUTION sta; and
f) comply with the POSTSECONDARY INSTITUTION and DISTRICT student code of conduct and other instuonal policies.
2. Rights and Privileges of Student
The right and privileges of STUDENTS parcipang in dual, concurrent or jumpstart credit courses include:
a) The rights and privileges equal to those extended to DISTRICT and POSTSECONDARY INSTITUTION students, unless otherwise excluded by any secon
of this Agreement;
b) The use of the POSTSECONDARY INSTITUTION library, course related labs and other instruconal facilies, use of the POSTSECONDARY INSTITUTION
programs and services such as counseling, tutoring, advising, and special services for the students with disabilies (dual/jumpstart enrollment only),
and access to POSTSECONDARY INSTITUTION personnel and resources as required; and
c) The right to appeal, in wring to the DISTRICT or POSTSECONDARY INSTITUTION, as applicable, any decision pertaining to enrollment in the dual,
concurrent or jumpstart credit program.
3. Condenality of Student Records
a) Student educaonal records created as a result of this Agreement shall be retained and disseminated in accordance with Family Educaonal Rights and
Privacy Act (FERPA) requirements.
b) Parcipaon in dual, concurrent or jumpstart credit courses requires STUDENT and, if applicable, PARENT/GUARDIAN signatures on the form for
compliance with FERPA regulaons.
4. Secondary School and Postsecondary Instuon Calendars
STUDENTS earning dual or jumpstart credits shall abide by the regular operang calendars, schedules and associated requirements of the POSTSECONDARY INSTITUTION.
If the calendars are incongruent, the dual and/or jumpstart credit STUDENT is required to independently sasfy both calendar requirements and may consult with
DISTRICT counselors for assistance.
Updated May 2016
9 10 11 12
College Approval: AFTER the high school has approved the student’s enrollment, the designated college ocial gives nal approval.
Student meets the college’s criteria for enrollment and any addional criteria as specied in the college’s MOU with the local district. Parcipang
students shall receive postsecondary credit for any course taken under this agreement (Wyoming statute 21-20-201).
Signature, College Designee
Date
High School Approval: All applicaons must be authorized by the designated school ocial.
ACT Scores English: _______ Reading: ______ Math: _______ Composite: _________ Date Taken: ______________
ACCUPLACER Scores (if applicable) Sentence Skills (English): _________ Reading: __________ Arithmec: ___________ Date Taken: ______________
This student has the academic ability and background necessary to perform well in the Elementary Algebra: __________
college courses listed above. I/We allow this student to enroll in the course (s) listed above. College Level Math: ___________
Course (s) “shall be counted towards the graduaon requirements of the district” and
“shall be made a part of the parcipang student’s records maintained by the district.”
Designated School Ocial (print name) Title
Designated School Ocial Signature Date
List of Concurrent, Dual or Jumpstart Enrollment
Concurrent Enrollment = College courses scheduled and taught in the high school and awarded high school and college credit.
Dual Enrollment = Regularly scheduled college courses that are not oered in the high school and awarded high school credit.
Jumpstart = Classes taken at the college site for only college credit.
Classes cannot be listed unl pre-requisites are met (COMPASS/ACT)
Student Name
Course Course Sec No. Course Name/Title Credit Check Concurrent, Dual Credit Time Instructor
Dept. No. Hours or Jumpstart
Conc Dual Jumpstart
Conc Dual Jumpstart
Conc Dual Jumpstart
Conc Dual Jumpstart
Conc Dual Jumpstart
Conc Dual Jumpstart
Conc Dual Jumpstart
Conc Dual Jumpstart
Place ACT sticker here
Student and Parent Approval: We /I, the student and/or parent or guardian, agree for the afore menoned student to enroll in the concurrent, dual and/or jumpstart credit
courses listed above oered in coordinaon with high school and Eastern Wyoming College.
We understand that
• The district sta will authorize course selecon for each term.
• All prerequisite requirements, including assessment and course placement, must be met.
• Any courses registered for, or grades earned, become a permanent part of the student’s high school and college record, and, therefore, may impact transferability
and nancial aid.
• The student is responsible to obtain approval from the high school representave for permission to drop or withdraw from a dual or jumpstart credit program
course.
We will cooperate with both the high school and Eastern Wyoming College in fullling student responsibilies. At the end of each semester, we authorize Eastern Wyoming
College to forward all grades of the listed courses to the high school.
According to the Family Educaonal Rights and Privacy Act (FERPA) of 1974, all rights of access to students’ educaonal records transfer from parent to student when the
student is enrolled in a postsecondary instuon. Except as allowed by FERPA, non-directory informaon from the educaon record will be disclosed only with the wrien
consent of the student. Directory informaon may be released without wrien consent. Please consult the EWC college catalog for a list of items included in directory
informaon.
As a parcipant in the concurrent, dual and/or jumpstart credit program, I, the student, understand that it is the responsibility of the postsecondary instuon to release
my grades to my high school. I have the right to inspect any wrien records released pursuant to this consent. I understand that I may revoke this consent at any me
but understand that revoking consent will exclude parcipaon in this program.
By signing below, I, the student, authorize Eastern Wyoming College to release informaon to the high school. I understand that informaon may be released orally,
electronically, or in the form of copies of wrien records.
We/I, the student and/or parent or guardian, cerfy that all the informaon furnished in this applicaon is true to the best of our knowledge. We understand that any
misrepresentaon of the facts may result in the immediate cancellaon of the student applicaon or registraon.
If the student is 17 or younger a parent signature is required.
Parent Signature (mm/dd/yyyy) Student Signature (mm/dd/yyyy)
(Students can not take more than 18 concurrent credits)
Eastern Wyoming College - Concurrent, Dual & Jumpstart
Total # of Credit Hours
Updated May 2016
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Eastern Wyoming College Concurrent Dual Jumpstart Registration Form

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Completed 26 July 2020

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