Fillable Grambling State University 2019-20 Dual Enrollment Student Application (Grambling State University)

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Grambling State University 2019-20 Dual Enrollment Student Application (Grambling State University)

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  • 23 check-boxes
  • 51 other fields

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Grambling State University
2019-20 Dual Enrollment
Student Application
Please type or print in dark ink.
I. TO BE COMPLETED BY STUDENT
1. College Year: 20_____
2. Is this your first semester participating in the Dual Enrollment
3. Last Name: _______________________First Name: ____________________ Middle Name: ___________________
4. Other names you might have used: ______________________________________________
5
6. Social Security Number (Required): _______ - ______ - _________
7. Date of Birth: Month: __________ Day: __________ Year: __________
8. Mailing Address: ___________________________________________________________________________________________________________
Street or P. O. Box City State Zip Code
9. Home Phone: (_____) ______________________ Cell Phone: (_____) __________________________ E-mail:____________
(Area code) Phone Number (Area code) Phone Number
10. In case of emergency, notify: ____________________________________________________(_____)______________________________________
Last Name First Name Relationship (Area code) Phone Number
11. Are If no, country of citizenship: _____________________________
12 Ethnicity/Race: This information is voluntary and the information will be used for federal and/or state law reporting purposes in a nondiscriminatory
manner consistent with civil rights laws.
-Hispanic)
-Hispanic) -American)
13. Student Tuition and Other Expenses
Application Fee- students are not required to pay an annual $20 application fee. Seniors are required to pay an application fee for admission to
the University for their freshman year.
Tuition- a discounted rate of $150 per three credit hour course will be charged for 2019-20.
Text books and Course Materials: Students are required to use the same textbooks , course materials, and supplies as regular college students.
14. Course, Number, and Title of college course(e,g. ENG 101, Freshman Composition I).
15. CERTIFICATION:
• I certify that all information I have provided in this application is correct.
• I have received a copy of the Dual Enrollment Student Eligibility Criteria Framework and if approved for participation I will
comply with all the requirements.
• I understand that I am enrolling as a Visiting/Guest Student at the college/university. Upon graduation from high school, if I desire to enroll at a
college or university, I will apply for admission as a regular student and must meet the college/university admission requirements.
• I understand that the college courses and high school and college grades earned in those courses in which I enroll through the Early Start/Dual
Enrollment Program will be on my permanent high school and college academic records.
• I acknowledge that: (1) I am enrolling in the course listed in section III. of this form; (2) it is my responsibility to OFFICIALLY WITHDRAW or
DROP a class I decide not to complete by the college/ university published deadline: and (3) if I withdraw from the college course or earn a college
grade other than A, B, C, or P in the course, I may not be eligible for Early Start funding in the subsequent semester.
__________________________________________________________________________________________________________________________
Student Signature
(over)
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II. CERTIFICATION - TO BE COMPLETED BY PARENT/CUSTODIAN (GUARDIAN):
• I certify that all information I have provided in this application is correct.
• I have received a copy of the Dual Enrollment Program Student Eligibility Criteria Framework and if my child is approved for
participation, he/she will comply with all the requirements.
• I understand that my child is enrolling as a Visiting/Guest Student at the college/university. Upon graduation from high school, if my child desires
to enroll at a college or university, he/she will apply for admission as a regular student and must meet the college/university admission
requirements.
• I understand that the college courses and high school and college grades earned in those courses in which he/she enrolls through the Early Start/
Dual Enrollment Program will be on her/his high school and college transcript.
• I acknowledge that: (1) my child is enrolling in the course listed in section III. of this form; (2) it my child's responsibility to OFFICIALLY
WITHDRAW or DROP a class he/she decides not to complete by the college/ university published deadline: and (3) if he/she withdraws from the
college course or earns a college grade other than A, B, C, or P in the course, he/she may not be eligible for Early Start funding in the subsequent
semester.
________________________________________________________________________________________________________________________
Parent/Custodian (Guardian) Signature Date
III. TO BE COMPLETED BY HIGH SCHOOL:
A. COURSE ENROLLMENT REQUEST: The High School Principal (or designee) must indicate the college course in which the student has permission to
enroll and the respective high school course in which the student will receive high school credit.
College Course
Dept/Number
College Course Title
College
Credits.
Max of 3
High School
(LDE) Course
Number
High School Course Title
High
School
Units
Early
Start
Funded
Y/N*
B. Name of High School ________________________________________________________________________
Name of College/University ___________________________________________________________________
C. ACT HS Code ____________ D. Current School Year: 20___ - 20___
st
nd
Semester
E. Student's current grade level:
th
Grade
th
th
Grade Number of Carnegie Units completed____
Career Area of Concentration (For Work Skills Courses ONLY) _
G. A copy of this student's PLAN, ACT or SAT Scores is attached. Work Keys Certificate is required for students to enroll in a college work skills course if they
do not have the required PLAN/ACT/SAT score.
I. Student earned a grade of ___ in the last college course in which s/he was enrolled for participation in the Early Start Program as evidenced by the
attached college transcript/grade report. S/he was enrolled in this course in the _________ semester/term of _______.
J. CERTIFICATION:
I certify that the student completing this application has permission to participate in the Early Start Program; that the information provided for this student by
the high school is correct, and that steps have been taken to ensure that enrollment for Early Start funded courses has been limited to 3 semester
credit hours.
________________________________________________________________________________________________________________________
Signature of Principal or Designee Date
IV. CERTIFICATION - TO BE COMPLETED BY COLLEGE/UNIVERSITY:
Accuplacer; that student meets all
Dual Enrollment Program and college/university requirements to be enrolled in the course listed in Section III.A. of this application,. I certify that our
college/university does adhere to the Board of Regents Academic Affairs Policy 2.19.
_______________________________________________________________________________________________________________________
Signature of College/University Official Date
August, 2018
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Grambling State University 2019-20 Dual Enrollment Student Application (Grambling State University)

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Completed 8 February 2021

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