Postsecondary Enrollment Options (PSEO)
Program Notice of Student Registration
2021-22
ED-001763-22
2021-22
Instructions: Complete an enrollment form for each instructional term and postsecondary institution the student attends. Once
Sections 1 and 2 are completely filled out, the next step is to work with the enrolling postsecondary institution to complete
Section 3. Note: Only postsecondary institutions submit this form to the Minnesota Department of Education (MDE).
College Student ID Number:
1. To be Completed and Signed by the Student and Parent/Guardian
Student Name (Last, First, M.I.) Gender Date of Birth (MM/DD/YYYY)
Address City ZIP Code Phone Number
Postsecondary Institution This Term Parent/Guardian Name Address (if different than above)
Public School Students: Minnesota Statutes, section 124D.09, subdivision 7, requires public school students to inform the
district by May 30 of each year of the pupil’s intent to enroll in postsecondary courses during the following school year to
assist the district in planning. A pupil is bound by notifying or not notifying the district by May 30.
Date I/we notified the public school of the intent to participate in PSEO for either semester of the
2021-22 school year.
My signature(s) below indicates that I/we are aware that if I/we have not notified the enrolling district by May 30, 2021,
and the enrolling district has not waived the deadline, I/we may be responsible for the postsecondary costs.
All Students: Minnesota Statutes, section 124D.09, subdivision 6, requires: students and parent/guardian sign a
statement indicating they have received PSEO information (
students); are aware counseling services are available; understand PSEO course responsibilities. We have received the
information required under Minnesota Statutes, section 124D.09, and are aware the student above is enrolling in
postsecondary courses.
including transportation reimbursement for qualified
Student Signature Student Email
Parent/Guardian Signature
(if student is under age 18) Date
Upon completion of Section 1, pass this form to the pupil’s secondary school for completion of Section 2.
2. To be Completed by Secondary/Nonpublic/Home School
Public Nonpublic Home School
Secondary/Nonpublic/Home School Name School Type (Select one)
Public School Student’s
MARSS* Number
Attending School District Name
Attending School District Number
Select student’s grade level during the 2021-22 school year. (Select only one): Grade 10 Grade 11 Grade 12
Note: High school graduates and 21-year-olds are not eligible.
Students may not enroll in PSEO courses in addition to a full high school class load. Does this student have at least one
free class period during the high school day? (Select one) Yes No
Is the above student eligible for program application? (See Page 3 for requirements) (Select one) Yes
No
My signature below certifies the student identified in Section 1 meets the eligibility requirements outlined on Page 3 for
participation in the PSEO program this term, and the information in Section 2 is accurate and applicable. The public
school student has notified the enrolling public school district of intent to enroll by May 30, 2021, or the public school
district has waived the deadline requirements.
Secondary School Contact Name Contact Signature Email Phone Date
M F
