Fillable IRSC Dual Enrollment Registration Form

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IRSC Dual Enrollment Registration Form

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The IRSC Dual Enrollment Registration Form form is 2 pages long and contains:

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  • 5 check-boxes
  • 58 other fields

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File type: PDF

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IRSC-68 Rev.10/2018
DUAL ENROLLMENT REGISTRATION FORM
(including Early Admissions/Collegiate High School/Home School)
Term: Year:
IRSC Student I.D. #:
–
Indian River State College’s Dual Enrollment program provides the opportunity for qualified high school
students who meet the eligibility criteria specified in their District’s articulation agreement, to enroll in college
courses while simultaneously enrolled in a public high school. Students receive both high school and college
credit for these courses. Dual Enrollment students are exempt from tuition, matriculation, and laboratory fees.
Textbooks for public high school students are provided by their District, and must be returned. Textbooks for
home school students are provided by IRSC and must be returned. Private School students are responsible
for acquiring their own textbooks and instructional materials.
STUDENT DATA (Please Print):
Last Name:
First:
Middle:
Street Address:
City:
ZIP:
Home Phone:
High School Name:
Date of Birth:
Present Grade: 9 10 11
12
Dual Enrollment Program cohort Types (junior & senior options) select one only if applicable.
Early Admission (high school senior - 6 semesters of secondary coursework completed): enrolled in 12
college credits per semester toward an Associate Degree and receive high school and college credit for
successful course completion.
Collegiate High School (high school junior or senior): enroll in 30 credit hours within academic
year, earn an industry certification, and receive high school and college credit for successful
course completion.
ACADEMIC DECLARATION: (Indicate GPA AND check the corresponding box below)
The student’s cumulative unweighted GPA is .
The student meets the unweighted GPA requirement of 3.0 for any college credit course or 2.0 for
vocational clock hour courses.
The student does not meet the GPA requirement, and exception pursuant to the IRSC/(School District,
Private School or, Home School inter-institutional Articulation
Agreement (Eligibility & Access Section 9 (a, b, c); OR Home School Section 12) is requested for the
following reason:
PLACEMENT DECLARATION (check one):
Placement Test (ACT, SAT, P.E.R.T) Test Date
Reading Writing/English Math
College Level all 3 subject areas
IRSC-68 Rev.10/2018
The student has not met placement criteria in all three areas, however may continue in Dual Enrollment
under rule 6A-14.064(b) because this student is enrolled in appropriate preparatory classes at the high
school, and has received written information relative to Associate Degree requirements, university
admissions and financial aid.
COURSE REQUEST(S): From the schedule of courses, list your choices (registration subject to space
availability).
COURSE #
HIGH SCHOOL
SUBJECT AREA
COLLEGE
CREDITS
HS
CREDITS
HIGH SCHOOL VERIFICATION: I verify that the above course(s) WILL be used to meet the student’s high
school graduation requirement, and will be posted to the student’s high school transcript.
Principal or Designee Date
IRSC Administration Date
STUDENT ACKNOWLEDGEMENT: I understand and accept the conditions of Dual Enrollment at IRSC and
understand that as a Dual Enrollment student, I am considered a dependent student and understand that
IRSC may release information from my Dual Enrollment academic record to my parents and/or high school
officials including grades, test scores, attendance and official transcripts.
Student Signature Date
White – IRSC Enrollment &
Student Services
Yellow - School District
Bookstore
Pink – Student Gold – HS Counselor
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IRSC Dual Enrollment Registration Form

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Completed 10 April 2020

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