Purpose: Students who are still enrolled in high school and want to take college classes at Lock Haven University-Clearfield Campus are to complete this form
each semester/summer session. Enrollment is limited based on space availability. Forms are to be submitted to the main office at the Clearfield Campus of
Lock Haven University no later than the deadlines below.
Select one of the following. Consult with your guidance counselor/principal for the appropriate choice for your enrollment.
_____ Enrolling under University/high school’s Dual Enrollment agreement. (Ineligible if receiving a dependent tuition waiver.) The following schools have a
signed agreement; other schools are not eligible.
Clearfield Area, Curwensville, Dubois, Harmony, Moshannon Valley, Philipsburg Osceola, and West Branch
The dual enrollment agreement, signed by your school district/high school and Lock Haven University, provides for registrations based on space availability. In
addition, registration forms must be received by the main office at Clearfield by the following deadlines: Fall semester enrollment May 15; Spring semester
enrollment -- December 1; Summer session enrollment May 1.
____ Dual enrollment does not apply.
PRINTED NAME Principal/Guidance Counselor _________________________________________________________Phone _________________
SIGNATURE-Principal/Guidance Counselor ___________________________________________________Date __________________
Signature indicates this student is eligible to enroll in the college course. For students registering under dual enrollment, signature also indicates the student
is eligible to receive high school credits from a university course..
From which campus will you be taking your course(s)? _____ Clearfield Campus _____eCampus
Full name and address of high school ______________________________________________ Expected graduation date _______________
Have you ever applied for formal admission to Lock Haven University? ____ Yes ____ No
SEMESTER/YEAR FOR WHICH YOU ARE REGISTERING - Semester____________ Year________
NAME______________________________________________________________ SS#__________/________/__________
last name first name middle initial/name (used only until an LHU ID is assigned)
ADDRESS________________________________________________________ TEL # (_______) _____________________
CITY_____________________________________________________________ STATE___________ZIP_______________
RESIDENCY STATUS: County____________________________________State__________Country___________________
DATE OF BIRTH ______/_______/______ CELL PHONE (______)_____________EMAIL ADDRESS ____________________
mo day year
SEX _______ MARRIED/SINGLE (optional)_________________ MAIDEN NAME (IF APPLICABLE)___________________________
US Department of Education Questions
What is your ethnicity? _____Hispanic or Latino ______ Not Hispanic or Latino
What is your race? Mark one or more races to indicate what you consider yourself to be.
___White ___ Black or African American ___ Asian ___ American Indian or Alaska Native ___ Native Hawaiian or Other Pacific Islander
STUDENT’S SIGNATURE ______________________________________________________Date______________________
Signature indicates that information contained on this form is true and correct AND authorizes Lock Haven University to release your academic record to your high
PARENT’S SIGNATURE _______________________________________________________Date______________________
Approve enrollment and agree to costs incurred by student’s registration and as defined by signed agreement between the district and the University
Course Number
Technology (ITV, Web,
RETURN COMPLETED FORM TO: LHU-Clearfield, 201 University Drive, Clearfield PA 16830 (Fax: 814-768-3449)
xc: Student Financial Services and Director of Distance/Continuing Education
Registrar’s Office 07/19/2011