DUAL ENROLLMENT
SIGNATURE PAGE
Step 1: Fill out the Online Application at www.ladelta.edu
Step 2: Follow instructions below and complete this form
Co
lleg
e
Se
mes
ter:
Fall
Winter
Sp
ring
Su
mmer
Year:
20
Current grade
level:
10
th Grade
11
th Grade
12
th Grade
High School
Name
Gen
de
r:
Femal
e
Male
Current GPA______
P
LA
N/A
CT Composi
te
____ En
g
lish ____ Math ____
Re
ading ____
La
st
Na
me:
First
Na
me:
Middle
Na
m
e:
So
cial
Secu
rity
Numb
er
(R
equi
re
d):
-
-
Date
of
Birth:
Month:
Day:
Year:
Mai
ling
Addre
s
s:
S
tre
e
t
or
P. O. Box
City
S
ta
t
e
Zip
C
od
e
Home Phone:
( )
E
-mai
l:
(
)
La
st
Name
First
Name
Relationship (Area code) Phone
Number
Student
Co
ns
ent
I have read and understand the following policies of the Louisiana Delta Community College (LDCC) Dual Enrollment program. I
understand that if I receive a final grade of D or F in any course, I may lose the privilege of continuing in any classes in the LDCC Dual
Enrollment program. I understand that if I withdraw from a course after the add/drop registration period, it will remain on my college
record, I may receive no college or high school credit for the course, and it may affect my future financial aid. Grades I receive in
college courses will remain on my permanent college transcript. I authorize Louisiana Delta Community College to release information
about my academic record to my high school while I am enrolled in the LDCC Dual Enrollment program. I understand that I will be
responsible for any enrollment cost.
Parental
C
onsent
I have read the LDCC Dual Enrollment admissions information, have been advised of the procedures involved in entering the
program and completely approve of my dependent’s participation. I further understand that Dual Enrollment students must meet and
maintain academic requirements for Louisiana Delta Community College and school board policies. I unde
r
stand tha
t
these classes are
not free and I must provide the required funding and/or documentation at the onset of the program for my child to continue. In case of
emergency you can be notified:
Student Signature Date: MM/DD/YY Parent or Guardian Signature Date: MM/DD/YY
High School
Consent
I certify that the student completing this application has permission to participate in the Dual Enrollment Program; that the information
provided for this student by the high school is correct, and verify that the applicant is eligible to participate in the dual enrollment
program.
Bill High School /
District
Bill Student Full
Amount
Tops Tech Early
Start
Pri
ncipal or Designee Signature Date: MM/DD/YY
Requested Courses
Supplemental Course
Academy
Previous Dual Enrollment Student
*If you need assistance because of disability, please contact the LDCC Counseling Center at (318)345-9152.
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