Fall 20______ Spring 20______ *Summer 20______
Registrar’s Office
Lansing Community College
411 N. Grand Ave.
Lansing MI 48933
Phone (517) 267-5806
High School Dual Enrollment Approval Form
This form is required for any high school student taking Lansing Community College (LCC) classes.
Section 1: Student Information (To be completed by student)
Last Name: First N
LCC Banner ID # Date of Birth
Street Address
City: State Zip Code:
High School Name or Home Schooled & Graduation Date:
Semester of Planned Dual Enrollment
Only Choose One. *Note: Summer semesters may not be covered by the Michigan Department of Education and/or school district
As a dual enrolled student at LCC, I certify that all the answers on this form are complete and accurate to the
best of my knowledge. I agree to become knowledgeable about LCC’s policies and procedures, including
those related to the adding/dropping of courses. I understand that I am creating a permanent LCC academic
record. I further acknowledge that I am aware that some college courses contain adult content.
Student Signature Date:
Section 2: Dual Enrollment Program and Payment Information (To be completed by High School)
Select which program(s)
you are participating in:
Traditional Dual Enrollment
(Select if HS/RESA is responsible for paying any portion of classes. If selected, complete
section 3, 5 and 6 only.)
State-Approved Non-Public High School (Select if attending a Non-Public School and the State of Michigan is
responsible for paying any portion of classes. If selected, complete sections 4, 5 and 6 only.)
High School Advantage (If selected, complete sections 5 and 6 only.)
Self-Payment Non-Home School (Select if classes are not fully financially covered by any other program. If selected,
complete sections 5 and 6 only.)
Self-Payment Home School (Select if Home Schooled and classes are not fully financially covered by any other program.
f selected, complete section 5 only.)
Section 3: Traditional Dual Enrollment (To be completed by High School)
*Amount covered to be determined
*Finalized amounts can be confirmed by either submitting a new form or by emailing LCC-HSDualEnrollment@lcc.edu
Finalized Amounts Listed Below
$ $
All Tuition/Fees Covered (If not all is covered, please indicate amount being paid)
Lansing Community College is an equal opportunity, educational institution/employer.
Last Revised: 05/01/2020
Amount Per Course OR Maximum Amount Authorized
Course Code
example: ENGL 121
Course Title
example: Composition I
Name of Institution Paying (If Not High School): ________________
Section 4 - State-Approved N on-Public High School (To be completed by High School)
The Postsecondary Enrollment Options Act (PA 160 or 1996) provides for payment from a school district’s
state aid foundation grant for enrollment of certain eligible high school students in postsecondary courses of
education. A student enrolled in at least one high school class in a state-approved non-public school in
Michigan may be eligible to participate and have amounts billed to the Michigan Department of Education,
detailing the tuition and fees of the dual enrolled pupil for all eligible courses enrolled.
Name of State-Approved Non-Public School:
Number of Cl
asses Considered Full-time at High Schoo
Section 5 - Parent/Legal Guardian Approval
(To be completed by Parent/Legal Guardian)
As the Parent/Legal Guardian of the above named student, I approve and understand the following:
Approve for my student to enroll at Lansing Community College;
If my student is a home school student; that they are only eligible for funding if they are enrolled in a
minimum of one class at a public high school or state approved non-public high school and are
for working with the respective school district for more information on eligibility
Acknowledge my student is participating in an adult educational environment, and I hereby assume
responsibility and hold LCC harmless for any adverse consequences of that participation;
Enrollment is contingent upon an available open seat in the course(s) selected;
Waive any claim against LCC for injury, loss or damage whatsoever, caused by any person rendering
any services of the program caused by outsiders;
Assume financial responsibility for any and all costs associated with attendance at Lansing Community
College, if not covered by any other means; and
Understand a FERPA release of information must be on file to review any of my student’s financial
Parent/Legal Guardian’s Full Name
Email Address Street Address:
Phone: City:
Signature Dat
Section 6 High School Principal Approval
(To be completed by High School)
Our School certifies that the above named student is currently enrolled with us and:
Meets the conditions outlined in the Michigan Postsecondary Enrollment Options Act
Has received the prescribed counseling required under
the Postsecondary Enrollment Options Act from
the sponsoring school;
Has demonstrated the skills and abilities to successfully complete the college courses recommended.
Conferred with the student and parent/guardian and believe that enrollment is in the best interest of the
Recommends the enrollment of this student at Lansing Community College for the approved semester
indicated above.
Acknowledges that the school district is responsible for payment of tuition and fees for the lesser
amount of (1) the actual charge for tuition and fees; or (2) the student’s authorized allowance,
regardless if
the student drops classes during LCC’s
refund period or
refund period.
Will notify LCC’s Registrar's
Office if any part of this approval needs to be updated and/or
High School Principal or designee’s full name
Email Address: P
Signature Date
Lansing Community College is an equal opportunity, educational institution/employer.
Last Revised: 02/05/2020