Dual Enrollment Program App Form

Student Information

First Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Email Address

Phone Number

Gender

Birthdate

High School

Current HS Level

Intended Semester Start

Intended College Major

Course Selections

*Students must meet all pre and co-requisites for a course, if required.

Choice #1

This course requires a lab. Please choose which you will be attending

Choice #2

This course requires a lab. Please choose which you will be attending

Choice #3

This course requires a lab. Please choose which you will be attending

Choice #4

This course requires a lab. Please choose which you will be attending

You will receive confirmation and further information on status once you have been registered.

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian address (if different from above)

Country

Street

City

Region

Postal Code

References

High School Principal Name (First & Last)

Guidance Counselor Name (First & Last)

Teacher/Advisor Name (First & Last)

File Uploads

Upload Transcript (optional)

Upload Parent Review and Consent Form

Upload Recommendation Form from Principal, Guidance Counselor, and Teacher/Advisor

Signature

Electronic signature
type your full name

Date