PALM BEACH STATE COLLEGE
DUAL ENROLLMENT AUTHORIZATION FORM
DE Form (01/2020)
Instructions
A Palm Beach State College admissions application must be completed if this is the students first time requesting
authorization to dual enroll. This form must be completed and submitted to the Admissions & Registration Office at any
Palm Beach State College campus.
PART 1 – Student Information Fall Spring Summer Year ______
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Last Name First Name PBSC Student ID Unweighted GPA
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Birth Date (MM/DD/YYYY) Current Grade Level Expected HS Graduation Date (MM/DD/YYYY)
PART 2 – Dual Enrollment Course Approval Dual Enrollment Early Admissions
This section must be completed by the student’s HS Dual Enrollment Designee/Home Education official. Please legibly write and
initial each requested course within the chart below. Courses that are illegible, have “white-out” under them or are crossed
out will not be processed.
PBSC Course ID (e.g. ENC1101)
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Name of School Telephone Number
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Name of Dual Enrollment Designee Signature of Dual Enrollment Designee Date (MM/DD/YYYY)
PART 3 – Student & Parent Certification
My signature indicates I have thoroughly read and will comply with the requirements and procedures of the Dual Enrollment
program at Palm Beach State College. I also understand that all courses while in the program will be posted to my permanent
college and high school records.
________________________________________________________________________________________________________
Student Name Student Signature Date (MM/DD/YYYY)
________________________________________________________________________________________________________
Parent/Legal Guardian Name Parent/Legal Guardian Signature Date (MM/DD/YYYY)
This form must be completed every term for which dual enrollment is intended.
Public/Charter Home Education Private
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