High School
Name
Current GPA______ ____ ____ ____ ____
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Year:
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Home Phone:
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La
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Name
First
Name
Relationship (Area code) Phone
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Student Signature Date: MM/DD/YY Parent or Guardian Signature Date: MM/DD/YY
Principal or Designee Signature Date: MM/DD/YY
Requested Courses
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This document contains both information and form fields. To read information, use the Down Arrow from a form field.
DUAL ENROLLMENT
SIGNATURE PAGE
Step 1: Fill out the Online Application at www.ladelta.edu
Step 2: Follow instructions below and complete this form
Previous Dual Enrollment Student
Student Information
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
Gen
de
r:
Femal
e
Male
P
LA
N/A
CT Composi
te
En
g
lish Math
Re
ading
- -
Parent Information
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.
*If you need assistance because of disability, please contact the LDCC Counseling Center at (318)345-9152
.
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:
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.
This docum
Bill High School /
District
Bill Student Full
Amount
Tops Tech Early
Start
Supplemental Course
Academy
