Dual Enrollment Application for Admission For High School Juniors and Seniors

Transcription

1 Application for Adission Office of Adissions 1665 Hapshire Pike Colubia, TN Dual Enrollent Application for Adission For High School Juniors and Seniors How do I apply? Step 1 Please coplete this for by printing clearly in ink or by typing. Step 2 Reeber to have appropriate signatures on the Adission Application, Hepatitis B Iunization Health History For, and the Consent For. Step 3 You ay subit your application in person at any Colubia State capus or ay ail your application to: Colubia State Counity College Office of Adissions 1665 Hapshire Pike Colubia, TN Step 4 Request that all official supporting docuents such as high school transcripts, consent fors and ACT scores be sent directly to the address above or faxed to Official docuents are those received fro the issuing agency/institution by ail, fax or in person. All subitted docuents becoe the property of the college and cannot be returned or forwarded. What else is required? New applicants are required to subit a $10 non-refundable, one-tie application fee payent with this application. To be considered for the Dual Enrollent Grant, students ust also coplete a Grant Application for prior to each seester by Tennessee Student Assistance Corporation (TSAC) deadlines. TDD Relay Nuber: Office of Adissions: Fax: Colubia State Counity College, a Tennessee Board of Regents Insitution, is an equal opportunity, affirative action institution. Individuals needing this aterial in an alternative forat should contact the associate vice president for students services or the appropriate progra director.

2 To be eligible for Dual Enrollent, the following ust be et: The student ust be a junior or senior in public, private, or authorized hoe-school (freshan and sophoores ust coplete the regular Application for Adission as acadeically talented/gifted ). Students wishing to take courses with prereqsuites (such as ath, ath-related science courses, English, speech, and literature courses) ust eet placeent requireents as follows NO EXCEPTIONS: College Subject ACT SAT COMPASS ath & related sciences 19 + ath ath ath reading intensive 19 + reading verbal reading English & speech 18 + English verbal writing Other Iportant Inforation Once aditted to the Dual Enrollent progra, students are expected to follow all college policies and are required to aintain a 2.0 cuulative GPA in college or they will not be able to continue in the progra. It is the student s responsibility to consult with the high school and/or local board of education to see how courses will count toward the student s high school graduation and/or be posted to the high school transcript. Dual Enrollent students ay not take Learning Support classes. Unless otherwise approved by the high school, students ay take their college classes at any Colubia State location at the days/ties designated in the seester schedules. Dual Enrollent students ust attend the classes for which they are registered. If the student does not plan to attend the class or soething changes in the student s schedule, it is the student s responsibility to officially drop the course(es). Once aditted to the Dual Enrollent progra, the college does not track the student s high school GPA. However, students should consult with their high school regarding any high school GPA requireents for continuation in Dual Enrollent. Dual Enrollent students taking college classes are assessed the sae fees and discounts as any other student. Dual Enrollent students once aditted are eligible for the Dual Enrollent Grant if subitted to the Tennessee Student Assistance Corporation (TSAC) by the required deadlines. High school students are NOT eligible for federal financial aid or college scholarships. After graduation fro high school, students are then eligible for federal and college aid. Students wishing to continue with Colubia State after graduation fro high school ust coplete the regular adission application and be aditted to the college as a regular student.

3 DUAL ENROLLMENT APPLICATION PLEASE CHECK ONE: First adission: ($10 fee required) Readission: (No fee required) *Social Security Nuber: - - Date of Birth: Full Legal Nae: Last First Middle Maiden/Forer nae Peranent Address: Nuber/Street/Apt # City State Zip Code County ( ) ( ) ( ) Hoe Phone Business Phone Cell Phone Personal Eail Address: Eergency Contact: ( ) Nae Relationship Phone nuber Gender: Male Feale Foreign Citizen, Per. U.S. resident Foreign Citizen, Country Citizenship: U.S. Citizen Type of Visa This inforation is requested for statistical purposes only. Responses given will not affect the status of your adissions file. Ethnic Origin: Do you consider yourself to be Hispanic/Latino/Spanish origin? Yes No In addition, select one or ore of the following racial categories to describe yourself: Alaskan Native Aerican Indian Asian Black or African Aerican Native Hawaiian or Other Pacific Islander White Selective Service: All ale U.S. citizens and non-citizens 18 through 25 years of age residing in the United States ust register with Selective Service prior to registering for classes at Colubia State. This does not apply to those exept by federal law including feales, non-iigrant aliens on student, visitor, tourist or diploatic visas, and active duty ilitary personnel. Indicate whether or not you have registered with Selective Service: I a not yet 18 Yes No Exept - Reason Residency: No student is classified as a Tennessee resident just by his/her ere presence in the state. Have you lived in Tennessee continuously for the past 12 onths? Yes No If you answered no, how long have you lived in Tennessee? onths How long have you lived at the peranent address listed? years onths Ter you plan to enroll Fall (August) Spring (January) Suer (May/July) Year 20 Which capus do you plan to priarily attend? (1) Colubia (2) Franklin (3) Lawrenceburg (4) Lewisburg (5) Clifton (6) Other Current High School: Nae of School City State I expect to graduate in the onth/year. Notice: I understand that if I a accepted into the Dual Enrollent progra that I ust eet prerequisites to all courses. By withholding or giving false inforation on this application, I ay be ineligible for adission to the college or subject to disissal. I understand that while a Dual Enrollent student, I ust eet the retention standards of the college. I consent to the release of attendance and final grades inforation to y high school. If I wish to continue at Colubia State after graduation, I ust provide the college with an official, final high school transcript and a regular Application for Adission. Applicant s Signature Date *In accordance with the Privacy Act of 1974, please be advised that the requested disclosure of your Social Security Nuber is voluntary and optional. Your Social Security Nuber will not be disclosed to individuals or agencies outside of the institution except in accordance with the institutional policy on student records.

4 DUAL ENROLLMENT CONSENT FORM (THIS IS NOT AN APPLICATION) Nae: Last (please print) First (please print) MI Date of Birth: Month/Day/Year Return for to: Colubia State Counity College Office of Adissions 1665 Hapshire Pike Colubia, TN TDD Relay Nuber (800) Phone: (931) Fax: (931) Social Security Nuber: - - SEMESTER AND YEAR: $10 Application Fee: Paid Online Check Enclosed Paid by Phone CONSENT FOR DUAL ENROLLMENT Parental / Guardian Consent: I give perission for to take Dual Enrollent classes with Colubia State Counity College. (print student s nae) I understand that grant or other financial support for Dual Enrollent ay not copletely cover costs. I understand that I will be responsible for payent of tuition, fees, books, and any other aterials and expenses associated with these classes. I understand that, due to federal regulations, federal aid (such as Pell grant) and regular college scholarships are not available for Dual Enrollent students. I understand that account billing will occur through eail notifications, and no paper bills will be ailed. I understand that to ensure propt account inforation is received, I can provide an eail address for the person responsible for this student s billing account. Parent/Guardian Signature Date Billing Eail Address (please print) AUTHORIZATION TO DISCLOSE ACADEMIC INFORMATION (FERPA) Federal Law prohibits a college fro discussing any inforation about a student without a written signed release fro the student. Student FERPA Release: I give y perission for Colubia State Counity College to release inforation to y high school officials and y parents & legal guardians, regarding attendance, grades, dual enrollent grant and fee payent (parent/guardian naes) inforation until I graduate fro high school. Student Signature Date PRINCIPAL / GUIDANCE COUNSELOR CONSENT: I certify that the above naed student has y perission to participate in the Dual Enrollent progra provided by Colubia State Counity College. This student s Grade Point Average (GPA) is on a 4.0 scale. Official docuents ust be sent fro the high school to Colubia State. There are three ways to transit official docuents: 1. Fax to Adissions at (931) Mail to 1665 Hapshire Pike, Colubia, TN Student can deliver in an unopened envelope. Official docuents include: Transcript ACT/PLAN/SAT Scores This For Sheet Principal or Guidance Counselor Date OFFICE USE ONLY APPLICATION FEE PAYMENT: CHECK NAME NUMBER CASH CREDIT CARD

5 Nae: Last (please print) First (please print) MI HEPATITIS B IMMUNIZATION HEALTH HISTORY FORM Hepatitis B Health History Inforation The General Assebly of the State of Tennessee andates that each public or private postsecondary institution in the state provide inforation concerning Hepatitis B infection to all students atriculating for the first tie. Tennessee law requires that such student coplete and sign a waiver for provided by the institution that includes detailed inforation about the disease. The required inforation below includes the risk factors and dangers of the disease as well as inforation on the availability and effectiveness of the vaccine for persons who are at-risk for the disease. The inforation concerning this disease is fro the Centers for Disease Control and the Aerican College Health Association. The law does not require that students receive vaccination for enrollent. Furtherore, the institution is not required by law to provide vaccination and/or reiburseent for the vaccine. Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver failure, and even death. The disease is transitted by blood and or body fluids and any people will have no syptos when they develop the disease. The priary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease is copletely preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are required for optial protection. Missed doses ay still be sought to coplete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong iunity in ost cases. I hereby certify that I have read this inforation and I have received the coplete three dose series of the Hepatitis B vaccine. Date of copletion of the Hepatitis B vaccination series: / / I hereby certify that I have read this inforation and I have elected to receive the Hepatitis B vaccine and/or I a in the process of receiving the coplete three(3) dose series of the Hepatitis B vaccine. I hereby certify that I have read this inforation and I have elected not to receive the Hepatitis B vaccine. Signature of Student or Parent/Guardian (If student is under 18) Date: For ore inforation about the Hepatitis B disease and its vaccine, please contact your local health care provider or consult the Center for Disease Control and Prevention Web site at ( * In accordance with the Privacy Act of 1974, please be advised that the requested disclosure of your Social Security Nuber is voluntary and optional. Your Social Security Nuber will not be disclosed to individuals or agencies outside of the institution except in accordance with the institutional policy on student records. Colubia State Counity College, a Tennessee Board of Regents institution, is an EOE/AA institution.