STOP: If you are enrolling in UCM Dual Credit courses for the  rst
time, complete the online Admission Application at ucmo.edu/apply
I hereby authorize and consent to the disclosure of my educational records between
University of Central Missouri and the Parent/Legal Guardian identi ed below.
is may include but is not limited to grades, registration, academic standing,
payment information, and collections. ______Student Initial
FERPA Student Release
Submit complete form to dualcredit@ucmo.edu or (660) 543-8333. Questions? Visit us at ucmo.edu/dualcredit or call (660) 543-4876
Enrollment Application
Legal Name:
Date of Birth: / /
UCM Student ID (if known):
High School:
Graduation Month / Year:
Last First MI
7 0 0 -__________________
By signing this agreement I acknowledge my understanding:
I am enrolling in a college-level course and that my work will be graded according to the same standards applied to college students in the same course.
•  e nal grade earned in this course will be entered into my permanent record at the University of Central Missouri.
In order to drop a class I must obtain a Drop form from my high school and return it to Dual Credit O ce prior to the refund/drop deadlines at ucmo.edu/dualcredit
I acknowledge I am participating at my own risk in this/these Dual Credit program(s) and UCM activities. I acknowledge that I understand this assumption of risk and agree
to waive and forever discharge any and all claims of negligence against UCM, its board, employees, volunteers, and all other persons or entities acting in any capacity on its
behalf related to my enrollment at UCM.
Student Signature: ___________________________________________________________________________ Date: _____________________________
Student Agreement
Course
Pre x & Number
Course Title
Instructor
Days/Times or CRN (if known)
Credit
Hours*
Delivery Method (Choose One)
E.G.
MO 1000 Intro to Being a Mule
Mrs. Jenny Mule
3
Face-to-Face Online I-TV
Face-to-Face Online I-TV
Face-to-Face Online I-TV
Face-to-Face Online I-TV
Face-to-Face Online I-TV
Course Request
* Th e Dual Credit rate for 2020-2021 is $89.90 per credit hour
I hereby grant permission for my child to enroll in the UCM Dual Credit program. I understand:
•  e subject matter of the course may be more complex and mature in nature. Expectations of student behavior and performance will be held to a higher standard.
Although courses are generally transferable, it is the student’s responsibility to ensure transferability with the college/university that she/he plans to attend. Tuition charges
will remain.
Student must submit an o cial Drop Form with the Dual Credit O ce if they no longer wish to be enrolled in the course. To have course history removed from the UCM
transcript and tuition & fees removed, form must be received by the published Last Day to Drop with 100% Refund date at ucmo.edu/dualcredit
Any and all fees not covered by the District will be the Students responsibility and the responsibility of the parent/legal guardian. UCM must receive payment in full by the
end of the course. Students with outstanding balances will be passed to a third-party collections agency.
I understand and acknowledge that this application includes, among other things, a negligence waiver and release of claims. I expressly state I am over the age of 18 and have
had su cient opportunity to review this document. I further certify I have read this document, understand it, and agree to be bound by its terms.
Parent/Guardian Signature: ____________________________________________________________________ Date: _____________________________
Parent/Legal Guardian Consent
(only for students under 18)
To be Completed by High School O cial
Note: Only complete this box for students enrolling in English, Math and/or General Chemistry.
ACT Math:__________ ACT English:__________ Accuplacer Math:__________ Accuplacer English:__________
Students with ACT Math scores below 22, or equivalent Accuplacer, indicate grade earned in Advanced HS Algebra or Algebra II here _____________
Cumulative GPA:____________ Dual Credit Semester:________________ Year:________________
Student Information
I certify information provided in this section is o cial and on school record. School O cial Signature: ______________________________________ Date: __________________
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