State of New Mexico
Dual Credit Request Form
Summer
Fall
Spring
School Year
Last Name First Name MI Date of Birth STARS Student ID# Social Security number *
Mailing Address City State Zip Residency NM County High School Name
Gender Ethnicity* Telephone Expected Graduation Date HS ACT Code High School GPA
The above-named student has been given permission to enroll as a dual credit student. Based on this student’s academic record and overall maturity, I feel
he/she will be successful in college level courses. Therefore, as high school representative, I recommend the student take the following course(s):
Schedule #
e.g. CRN #
Course #,
e.g. MATH
121
Course
Section #
Course Title, e.g. College
Algebra
Day(s)
(MTWThF)
Time, e.g.
1-1:30pm
Location of Course
Education
High
School
Credits
We, the student and parent/guardian, agree for the above-named student to enroll in the Dual Credit Program offered in coordination with stated high school and
postsecondary institution. We understand the high school representative will authorize course selection for each term. We understand that all prerequisite requirements,
including assessment and course placement must be met.
We agree to abide by the guidelines in the Statewide Dual Credit Master Agreement, and high school and postsecondary policies and codes of conduct.
We will cooperate with both the high school and postsecondary institution in fulfilling student responsibilities. We understand that any courses registered for, or grades
earned, become a permanent part of the student’s high school and college record. At the end of each quarter and/or semester, we authorize the postsecondary institution to
send all grades to the postsecondary school, including those for courses that are not a part of this agreement.
We understand that it is the student’s responsibility to receive approval from the high school representative for permission to drop or withdraw from the course(s) listed above.
According to the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99), all rights of access to the student’s educational records transfer
from parent to student when the student is enrolled in a postsecondary institution. Accordingly, dual credit students still enrolled in high school have rights of access to their
postsecondary dual credit records. In order for the student to receive credit, transcripts of dual credit courses will be shared among the secondary and postsecondary
institutions the public education department, and the higher education department. All data submitted to secondary and postsecondary institutions or the NMHED will be used
and maintained in accordance with all federal and state statutes, regulations, and policies.
By signing below, I, the student, authorize the postsecondary institution listed above, to release all information concerning my academic records to my high school, the
NMPED, and the NMHED. I understand that information may be released orally, electronically, or on paper. I have the right to inspect any written records released pursuant
to this consent and understand that I may revoke this consent at any time.
We, the student and parent/guardian, certify that all the information furnished in this application is true to the best of our knowledge. We understand that any
misrepresentation of the facts may result in the immediate cancellation of the student application or registration.
High School Representative Signature Date High School Representative Name (print/type)
Student Signature Date Postsecondary Representative Signature Date
Parent/Guardian Signature Date Postsecondary Representative Name
Student Information
*Social Security number or ethnicity are not required for dual credit participation.
FERPA Release Information
Signatures
Course Listing and Secondary/Postsecondary Approval
HD
Dual Credit Form Received by (print/type name Date Entered by (print/type name) Date
Completed/Signed Dual Credit Request
Student meets course(s)
Student high school transcript
received (if applicable)
ACT Scores Postsecondary Institutional PLACEMENT Scores
English Math Reading Reading Writing Math
A. STUDENTS AND PARENTS OR GUARDIANS
Endorsement of the Form by the STUDENT and PARENT, unless the STUDENT is 18 years old, shall be evidence that they possess an awareness of, and agree with the
following provisions. For purposes of this agreement, Local Education Agency (LEA) means public school districts, state chartered charter schools, state-supported
schools and bureau of Indian education-funded high schools.
1. Admission and Enrollment of Students. For a student to be accepted and enrolled into a dual credit program, the STUDENT shall:
a. Discuss potential dual credit courses with the appropriate LEA and POSTSECONDARY INSTITUTION staff, including POSTSECONDARY INSTITUTION
admission and registration requirements, course requirements, credits to be attempted, credits to be awarded, scheduling under dual credit, and implications
for failure to successfully complete the course;
b. Obtain course requirements for each course, including course prerequisites, course content, grading policy, attendance requirements, course completion
requirements, performance standards, and other related course information;
c. Meet the prerequisites and requirements of the course(s) to be taken;
d. Complete the Form available online or in hard copy from LEA or POSTSECONDARY INSTITUTION;
e. Return the Form with the specific courses requested, required signatures and, if applicable, a current high school transcript, and copies of any assessment
results to LEA representative;
f. Obtain approval for enrolling in the dual credit program each semester by acquiring all necessary signatures on the Form and submit form to POSTSECONDARY
INSTITUTION representative;
g. Register for courses during POSTSECONDARY INSTITUTION’s standard registration periods (Note: enrollments shall not be permitted after the close of posted
late registration);
h. Discuss any request for a change in registration (add, drop, withdrawal), recognizing that “audit” is not allowed for a dual credit course, and complete all
necessary forms and procedures with appropriate LEA and POSTSECONDARY INSTITUTION staff; and
i. Comply with POSTSECONDARY INSTITUTION and LEA student code of conduct and other institutional policies.
2. Rights and Privileges of Student. The right and privileges of STUDENTS participating in Dual Credit include:
a. The rights and privileges equal to those extended to LEA and POSTSECONDARY INSTITUTION students, unless otherwise excluded by any section of this
Agreement;
b. The use of POSTSECONDARY INSTITUTION library, course related labs and other instructional facilities, use of POSTSECONDARY INSTITUTION programs and
services such as counseling, tutoring, advising, and special services for the students with disabilities, and access to POSTSECONDARY INSTITUTION personnel and
resources as required; and
c. The right to appeal, in writing to LEA or POSTSECONDARY INSTITUTION, as applicable, any decision pertaining to enrollment in the dual credit program.
3. Financial Responsibility for Funding Dual Credit. The STUDENT shall:
a. Return the textbooks and unused course supplies to LEA when the student completes the course or withdraws from the course;
b. Arrange transportation to the site of the dual credit course. Depending upon the time and course location, the student may have access to transportation
through LEA if the dual credit course is offered during the school day; and
c. Be responsible for course-specific (e.g. lab, computer) fees.
4. Confidentiality of Student Records.
a. Student educational records created as a result of this Agreement shall be retained and disseminated in accordance with FERPA requirements;
b. Participation in dual credit courses requires STUDENT and/or PARENT/GUARDIAN signatures on the Dual Credit Form to comply with FERPA regulations.
5. Secondary School and Postsecondary Institution Calendars.
The regular operating institutional calendar and schedule of POSTSECONDARY INSTITUTION shall be observed by STUDENTS earning dual credits. Dual credit
STUDENTS are required to comply with the requirements of both LEA and POSTSECONDARY INSTITUTION official calendars. In instances in which the calendars
are incongruent, the dual credit STUDENT is required to independently satisfy both calendar requirements and may consult with school counselors for assistance.
B. LEA. Endorsement of the Dual Credit Form shall be evidence the LEA has and will comply with the provisions outlined in the Agreement between the
POSTSECONDARY INSTITUTION and the LEA.
C. POSTSECONDARY INSTITUTION. Endorsement of the Dual Credit Form by the POSTSECONDARY INSTITUTION shall be evidence that the POSTSECONDARY
INSTITUTION has and will comply with the provisions outlined in the Agreement between the LEA and POSTSECONDARY INSTITUTION.
Rev.12/13
Administrative Purposes at the Postsecondary Institutions
Other Comments:
Agreement of Parties
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