Check the box in front of the college to identify where you plan to receive credit.
Chandler-Gilbert Estrella Mountain GateWay Glendale Mesa
Paradise Valley  Phoenix Rio Salado Scottsdale South Mountain
Dual Enrollment
Registration Form
Total Semester Credits x Credit Hour Rate $ = $ + $15 Registration Fee TOTAL AMOUNT DUE $
Legal Name: Date of Birth (MM/DD/YYYY):
Last First Middle HS Grade Level: 9 10 11 12
College ID # (Required) Email:
To locate your student college ID number, log in to your Student Center at my.maricopa.edu with your (MEID) and password, scroll down to the Personal Information section, and click “Demographic Data”.
Your student college ID number will be the rst item listed at the top of the page.
Mailing Address/Apt. #/City/State/Zip Code:
High School Name: Expected High School Graduation Date:
MM/YY
THIS BOX TO BE FILLED IN BY HIGH SCHOOL OR COLLEGE OFFICIAL
SAIS #: (Student Accountability Information System) (Required)
Check all that apply:
PSAT ≥ 93 SAT ≥ 930 ACT ≥ 22 AzMERIT ≥ Proficient ELA MATH
HB2008 ID Prerequisite Maricopa Grant
I have reviewed the information on this form, and certify that the student is eligible to participate in dual enrollment.
Ofce Use Only
Term:
Date:
Initials:
PLEASE PRINT
Term
(example: Fall, Spring)
In-state tuition* is $86 per credit hour, plus a $15 registration fee. In some cases, your high school or other party may subsidize the rate per credit hour.
*To qualify for in-state tuition students must provide proof of lawful presence in the United States. According to Arizona law, students who are not citizens or legal
residents, or who do not submit residency documents, will be charged out-of-state tuition. For more information go to maricopa.edu/residency.
STUDENT - PLEASE READ AND SIGN HERE:
I agree to the exchange of academic information between the participating institutions,
including but not limited to college grade reports, transcripts, and any other pertinent
documents. I give permission to release Maricopa Community Colleges student
information to my parents and/or legal guardian in accordance with Federal law.
Student Signature Cell Phone Number
(If no Cell Phone put Home Phone)
Date
Signature of Official Date
Accuplacer Score:
WritePlacer
Elem. Algebra
College Algebra
Reading
AP Score:
ENG
Calc A/B
Calc B/C
A.R.S 15-901 requires students to be currently enrolled at the school for a full-time instructional program in addition to the college course.
NOTE: High School Seniors who satisfy high school graduation requirements are exempt.
3
REV 06/14/17
High School
Ocial
MCCCD
Ocial
Year
(example: 2012)
Course Prex
(example: ENG 101)
Class Number
(example: 12345)
Instructor
Parent/Guardian Email
PARENT/GUARDIAN - PLEASE READ AND SIGN HERE:
As a parent or legal guardian, I give permission for the above named student to enroll
in the course(s) listed above. I agree to notify the Dual Enrollment Oce at the
college of choice regarding changes in enrollment, including dropping, adding,
or changing classes. Failure to pay will result in the above-named student being
automatically dropped from class(es) without notication. I understand that the
above named student will be establishing a college academic record and will be required
to report such enrollment to future colleges or universities. He/she will be subject to the
course requirements, grading standards and attendance requirements established by the
instructor in the course syllabus. I further understand that the above-named student will
be subject to all of the requirements, policies, regulations, and deadlines dened in the
College Catalog and Schedule of Classes.
Parent/Guardian Printed Name
Parent/Guardian Signature Cell Phone Number
(If no Cell Phone put Home Phone)
Date
Class Hour
(example: 1st hour)
Credits
(example: 3)
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
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