SUPPORTING MATERIALS
Have you ever been expelled, suspended, or placed on probation by any secondary school or college
you attended for academic dishonesty or because of an oense that harmed or had the potential to harm others?
m Yes m No
Have you ever been convicted of a criminal oense other than a minor trac violation, or been found
to be delinquent by a juvenile court, or are there such charges currently pending against you at this time? m Yes m No
If you answered yes to either of the questions above, you must include a separate, detailed statement of explanation.
ENROLLMENT INFORMATION (To be completed by Standard and DEEP applicants. Please complete one.)
Standard Dual Enrollment:
Anticipated date of enrollment (Enter year)
m September - Fall 20______ m January - Winter 20______ m May - Spring 20______ m July - Summer 20______
Please list the courses you plan to take:
Will your school or the state of Michigan be assisting you with the cost of attendance?
m Yes m No
Dual Enrollment Educational Partnerships (DEEP):
Which Location?
Which Semesters (check all that apply)?
m September - Fall 2018 m January - Winter 2019
m May - Spring 201
9
Which Program?
PERSONAL INFORMATION
By my signature, I certify that the answers I have given to all questions on this application are correct and complete to the best of my knowledge. I understand that falsication or omission
of information or credentials may result in revocation of admission. I understand that I am responsible for following the University of Michigan-Flint’s registration policies. If I fail to
comply with the University’s policies, I understand that I will be responsible for any charges that are incurred. Additionally, I understand my signature below authorizes the University of
Michigan-Flint to release my academic information including, but not limited to grades, transcripts, enrollment, and attendance records to my current school or third party agencies, school
district administrator(s), and intermediate school district (ISD) administrator(s) each term during my attendance as a student.
Student Signature (required) Date
My son/daughter has my approval to enroll as a dual enrolled student at the University of Michigan-Flint. I understand that I am responsible for payment of charges incurred by my child that
are not covered by the school district for all dual enrollment terms.
Parent Signature (required) Date
PAYMENT AUTHORIZATION (To be completed by public school ocials.)
The school district identied below commits to provide nancial support pursuant to state regulations in support of dual enrollment.
Name of High School
High School Ocial Signature Title Date
Any balance not covered by the high school is the student’s/parent’s responsibility
IN-STATE TUITION GUIDELINES
Are you a Michigan resident? m Yes, since (month/year): m No
If you have lived outside the state of Michigan in the last three years, please list the most recent state (or nation if outside the US) and approximate dates you lived there.
If any of the following circumstances listed below apply, you are required to le an Application for In-State Tuition if you wish to be considered for in-state tuition assessment.
• You live outside the State of Michigan for any purpose.
• You attended or graduated from a college outside the State of Michigan.
• You lived or worked outside the State of Michigan at any time within the last three years.
• You are not a U.S. citizen.
• Your spouse, partner, or parent is in Michigan as a nonresident student, medical resident, fellow or for military assignment or other temporary employment.
• You are 24 years of age or younger and a parent lives outside the State of Michigan.
• You are 24 years of age or younger and attended or graduated from a high school outside the state of Michigan.
• You attended or graduated from an out -of -state high school and have been involved in educational pursuits for the majority of time since high school graduation.
• You attended any University of Michigan campus (Ann Arbor, Dearborn, or Flint) as a nonresident.
Questions pertaining to your residency status can be answered by sta in the Residency Classication Oce, University of Michigan Oce of the Registrar, 1210 LSA Building, 500 South
State Street, Ann Arbor, MI 48109-1382, phone (734) 764-1400. To apply for in-state tuition classication visit www.ro.umich.edu/resreg.php.
Payment Authorization Waved
Signed DEEP Agreement With High School
