Kirtland Community College
DUAL ENROLLMENT FORM FALL 2020
PLEASE RETURN COMPLETED FORM TO teresa.money@kirtland.edu
Revised 5/2020
For office use only
RECEIVED __________
SS # _______________
RECORDED _________
COPY TO FS ________
FOR OFFICE USE ONLY
RE processed ___________ on ___________
initials date
Name ______________________________________________________ Kirtland ID# ______________________
Student Cell Number ( ) ________________________________School District ___________________________
Date of Birth ___________________________ Social Security Number (required if not on application)____________________________________
Semester/Year _____________ Program of Study ________________________ Early College Student: Yes____ No ____
The Postsecondary Enrollment Options Act requires local school districts to use funds allocated to them by the State of Michigan for the payment
of college tuition, mandatory course fees, materials fees, and registration fees of “eligible” high school students. Eligibility is determined by the
high school when certain conditions have been met by the high school student. To obtain a tuition and fee quote, please call the KCC Student
Financial Services at (989) 275-5000, ext. 257.
NOT ELIGIBLE: This student does not meet the criteria for funding. Therefore, the student is responsible for all tuition and fee charges.
ELIGIBLE: This student is eligible for financial assistance. The high school will pay all tuition, fees, and books for courses approved below up to
$______________________.
ALLOW BOOK PURCHASE @ KIRTLAND COMMUNITY COLLEGE BOOKSTORE? YES NO
College Courses to be taken through Kirtland Community College
COURSE NUMBER
(please include section number, i.e. 50, 60, etc.)
COURSE NAME
Principal Signature __________________________________________ Date ________________________
Disclaimer: Please understand that this student may be taking a class in a college setting with adults. The course content may at
times contain materials intended for an adult audience. Please discuss this with the student. Please also understand the instructor
may not discuss grades, etc. without permission from the student, and the parent may be responsible for payment.
Parent Signature ___________________________________________ Date ________________________
Records Release: For the purpose of providing educational information, I hereby grant permission to Kirtland Community College to
release any records or necessary pertinent information to authorized personnel of the high school listed above.
Student Signature __________________________________________ Date _________________________
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