DUAL/JOINT APPLICATION

Transcription

1 DUAL/JOINT APPLICATION for Admission A Tennessee Board of Regents Institution Moore County P. O. Box 8500 Lynchburg, TN McMinnville Center 225 Cadillac Lane McMinnville, TN Fayetteville Center 1802 Winchester Highway Fayetteville, TN Smyrna Teaching Site 5002 Motlow College Blvd. Smyrna, TN

2 Dear High School Student, Thank you for your interest in Motlow State Community College. We are delighted you have chosen our Dual/Joint Enrollment Program to begin your college career! Whether you are looking to take one class or complete your Associates Degree while still in high school, Motlow College is dedicated to academic excellence and helping you meet your educational goals. Beginning with the academic year, the Dual Enrollment Grant makes earning college credits as a high school student even more affordable for students meeting eligibility requirements. The attached Dual/Joint Enrollment Application Packet contains all of the information and forms you need to get started. Please review the following information carefully with your parents or guardians: Motlow College Dual Enrollment Frequently Asked Questions Motlow College Dual Enrollment Checklist Dual/Joint Enrollment Application for Admission Dual Enrollment Form Hepatitis B Immunization Health History Form Dual Enrollment Grant Frequently Asked Questions (note separate sheet for Juniors and Seniors) NOTE: The application process must be complete before students can be accepted by Motlow College. This includes completing all questions and signatures on the forms in ink. Students (not parents) are required to sign the Application for Dual/Joint Enrollment Admission. Students should bring the completed stapled pages from the packet to the high school on the date indicated by the high school counselor. Pages can also be returned to the Motlow College address listed on the Dual/Joint Application for Admission. The additional pages should be kept for your future reference. Effective April 1, 2015, Motlow College no longer requires an application fee. Thank you again, for your interest in Motlow College Dual/Joint Enrollment! If you or your parents still have questions after reviewing the attached documents, please feel free to contact us. We look forward to helping you reach your academic goals! Sincerely, Lori Mevis High School Partnership Program Specialist lmevis@mscc.edu (931) (931) FAX Serving students in Bedford, Coffee, Franklin, Moore, and Rutherford Counties Mrs. Laura Monks Director, Fayetteville Center lmonks@mscc.edu (931) (931) FAX Serving students in Franklin and Lincoln Counties Mrs. Melody Edmonds Director, McMinnville Center medmonds@mscc.edu (931) (931) FAX Serving students in Cannon, DeKalb, Van Buren, Warren and White Counties P.O. Box 8500 Lynchburg, Tennessee (931) or (800)

3 Dual/Joint Enrollment Frequently Asked Questions What is the difference between Dual and Joint Enrollment? Dual enrollment means you get credit for both a high school and a college class at the same time one class that gets counted two places. It really is a great deal! Joint enrollment means you are taking a college course while still enrolled in high school, but only earning college credit for the course. Your high school counselor can tell you whether the class you are taking qualifies as dual or joint enrollment for high school purposes. With either option, you are still earning college credit! Why take dual/joint enrollment classes? An immediate benefit is to save money, but other benefits include getting a jump start on your college career and gaining some experience and confidence about college level work through an easier transition. What are the requirements to qualify for a dual/joint enrollment course? A high school student wishing to take a dual/joint enrollment course at Motlow College must meet all of the following requirements: o Student must have completed the 10th grade. o o Student must have parent/guardian approval. (signature required on application) Student must have approval of high school principal or guidance counselor. (signature required on application) Student must provide an official ACT/ACT Plan report dated within the past three years with the required sub-score as outlined below. ACT/ACT Plan scores on the high school transcript are acceptable. Students who wish to take: A collegiate mathematics or science course must have a reading sub-score of 19 or greater, a writing sub-score of 18 or greater, AND a mathematics ACT/ACT Plan mathematics sub-score of 19 or greater. Any other collegiate course (for example: English, History, Music, Psychology) must have a reading sub-score of 19 or greater AND an English sub-score of 18 or greater. What if my ACT or PLAN scores are not high enough for me to be eligible for a dual/joint enrollment course? Is there anything else I can do to qualify? Students with ACT scores that do not meet the dual/joint enrollment required scores may challenge the ACT scores by taking the COMPASS exam on our campus. Students with PLAN scores below the minimum required scores may take the Residual ACT that is valid only for Motlow College. The results of this test cannot be sent to other colleges or used to apply for the Tennessee Lottery Scholarship. You must have completed a Motlow College application to be eligible for the Residual ACT. To find out test dates and times and to schedule a test, call our testing center at (800) ext or (931) How do I request a copy of my Motlow College transcript when I graduate from high school? Official transcripts can be sent directly to another educational institution or business only by written request from the student. Complete a transcript request form to have your Motlow College academic records sent to another college or university. You can access the transcript request form at You can also pick up these forms at any Motlow location. Transcript requests can also be submitted by mailing a signed request including your name and Motlow Student A# and the address you would like the transcript to be sent.

4 Dual Enrollment Grant Frequently Asked Questions Seniors ) If I am a Senior during the academic year and I have never taken a dual enrollment grant course, how much grant money will I be eligible to receive if I take my first dual enrollment course? If you take your first dual enrollment grant course as a senior and have been a Tennessee resident for the last twelve months you will be eligible to receive funding in the amount of up to $100 per credit hour. 2) If I am a Senior during the academic year and I have never taken a dual enrollment course, how much grant money will I be eligible to receive if I take two dual enrollment courses? If you take two dual enrollment courses and meet the Tennessee residency requirement as stated in question #1, you will be eligible to receive funding in the amount of up to $100 per credit hour. However, you must have a minimum 3.0 high school GPA or a minimum 21 ACT (980 SAT) Composite to receive funding for the second course. If both courses are three credit hours each then you will receive a total of up to $600 ($100 x 6 credit hours). Home school students must have a minimum 21 ACT Composite (980 SAT) in order to receive the additional $300 dual enrollment grant for a maximum of up to $600. 3) If I am a Senior during the academic year and I take three or more courses in the same semester, am I eligible for additional grant assistance? No. Seniors may receive funding for up to two courses per semester provided they have met the minimum GPA or ACT/SAT requirements to qualify for the HOPE Scholarship. Students who have not met the minimum HOPE Scholarship requirements (GPA or ACT/SAT) are eligible to receive funding for one course per semester provided continuing eligibility is maintained. 4) How do I maintain dual enrollment grant eligibility semester to semester? Students must maintain a minimum 2.75 college GPA for continued grant eligibility. 5) If am a Senior during the academic year and I have previously received dual enrollment grant funds, will I still be eligible for dual enrollment grant funds? Yes, as long as you maintained a minimum 2.75 college GPA. 6) If I am a Senior during the academic year and I have previously received dual enrollment grant funds, when will grant money begin deducting from my HOPE scholarship? Your grant funds will be deducted from your HOPE scholarship on a dollar for dollar basis when you receive funding for your fifth dual enrollment course. The funds will be deducted from your HOPE Scholarship in your freshman year of attendance until the funds are repaid. 7) If I am a Senior during the academic year and I take a four credit hour course, how much grant money would I be eligible to receive? Provided you meet all requirements to participate in the dual enrollment grant, you will be eligible to receive funding of up to $100 per credit hour. For a four hour course, you may receive up to $400 in dual enrollment grant funds. 8) What is the maximum amount of grant money that I would be eligible for each academic year? Seniors may receive up to $1,200 each academic year ($600 maximum per semester) provided the student has met the HOPE Scholarship eligibility requirements to do so.

5 Dual Enrollment Grant Frequently Asked Questions Juniors 1) If I am a Junior during the academic year and I take my first dual enrollment course, how much grant money can I receive? Juniors who take their first dual enrollment course and who have been a Tennessee resident for 12 months prior to the date of application will be eligible to receive up to a $500 dual enrollment grant. 2) If I am a Junior during the academic year and I take my second dual enrollment course, how much grant money can I receive? Juniors who take their second dual enrollment course and who have been a Tennessee resident for 12 months prior to the date of application will be eligible to receive up to a $500 dual enrollment grant. 3) How much will I receive if I take my first and second dual enrollment courses in the same semester? Juniors who have a minimum 21 ACT Composite (980 SAT) or a minimum 3.0 High School G.P.A. have the opportunity to take a second dual enrollment course in the same semester. Juniors who take their first and second dual enrollment grant courses in the same semester may receive up to $1,000 (up to $500 for each course). Home school students must have a minimum 21 ACT Composite (980 SAT) in order to take a second dual enrollment grant course in one semester and may receive up to $1,000 (up to $500 for each course). 4) How much dual enrollment grant money will I be eligible to receive for my third dual enrollment course? When you take your third dual enrollment course, you will be eligible to receive up to a $200 dual enrollment grant as long as you maintain a minimum 2.75 college GPA. 5) How much dual enrollment grant money will I be eligible to receive for my fourth dual enrollment course? You will not be eligible to receive any dual enrollment grant money for your fourth dual enrollment course. 6) In my junior year, what is the maximum amount of grant money that I will be eligible to receive each academic year? Students may receive up to $1,200 each academic year, provided the student has met the HOPE eligibility requirements to do so. 7) After I take four dual enrollment courses, will I be eligible to receive dual enrollment grant money? Yes, you will be eligible to start borrowing from your HOPE Scholarship beginning with your fifth dual enrollment grant course. This will allow you to receive up to $100 per credit hour. Funds received for the fifth through eighth courses will be deducted from your HOPE Scholarship on a dollar for dollar basis until the funds are repaid. As mentioned in question two, students who have met the continuing GPA requirement and have a minimum 21 ACT Composite or 3.0 High School GPA may take a second course. This will allow the student to receive the award for two courses (up to $600 per semester). Home school students must have a 21 ACT Composite (980 SAT) in order to receive funding for a second dual enrollment grant course. 8) If I am a Junior, can I use all $1,200 of my allotted dual enrollment grant within the same semester? No. Juniors may use up to $1,000 of the dual enrollment grant during one semester if they take their first and second courses in the same term. The $200 dual enrollment grant for the third dual enrollment course may be used the following semester. 9) How do I maintain dual enrollment grant eligibility semester to semester? Students must maintain a minimum 2.75 college GPA for continued grant eligibility. 10) If I am a Junior and I take one dual enrollment course during the fall semester of my Junior year and one dual enrollment course during the spring semester of my Junior year, how much dual enrollment grant money will I be eligible to receive for my third dual enrollment course during the fall semester of my Senior year? You will be eligible to receive up to a $200 dual enrollment grant for your third course. You will not be eligible for any dual enrollment grant assistance for your fourth dual enrollment course. 11) If I use $1,000 of dual enrollment grant funding during my junior year, would the additional $200 roll over to the next academic year since dual enrollment students can use up to $1,200 of dual enrollment grant each academic year? You will receive up to a $200 dual enrollment grant for your third dual enrollment course and you would not receive any funding for your fourth course. You will be allowed to start borrowing from your HOPE scholarship beginning with your fifth dual enrollment course as stated in question #7. 12) If I take my first dual enrollment course during my Junior year and then take my second dual enrollment course during my Senior year, how much grant money will I receive per class? You will receive up to $500 for the first course if you meet the Tennessee residency requirements. You will receive up to $500 for the second course if you maintain a minimum 2.75 college GPA.

6 Completing a Motlow College Degree Regardless of your future college plans past high school, an Associates Degree from Motlow State Community College is a very valuable credential for your resume. Once earned, a college degree is yours forever. Even if life gets in the way of you completing a bachelor s degree, having a degree from Motlow College may give you the edge in receiving future job offers and promotions. While some students use their dual/joint enrollment courses to try out college or to get a jump start on their degree, others use the opportunity to pursue their Associates Degree, either while enrolled in high school, or through a reverse transfer agreement with a four-year institution. Students wishing to complete their degree while still in high school are encouraged to talk to their high school guidance counselor early in their high school career to ensure they are prepared to begin college courses after their 10 th grade year. Students should also meet with Motlow College Dual/Joint Enrollment advisor before starting college courses. The Dual/Joint Enrollment Advisor will work with you and your high school guidance counselor to help you map out a plan for graduation. Students choosing to transfer their Motlow credits to a four-year institution after high school can earn a Motlow College degree while enrolled in the other institution once they have fulfilled the Motlow College degree program requirements, provided at least 15 collegiate hours were earned through Motlow State Community College. In order to qualify for your Associates Degree from Motlow College, you must complete: At least 60 collegiate hours meeting the Motlow College General Studies degree option At least 15 collegiate hours completed through Motlow State Community College Provide an official transcript of all your college courses Earn a cumulative grade point average of not less than 2.00 ( C average) for the degree program, excluding all hours earned in learning support courses Intent to Graduate form at least six months prior to intended Motlow graduation date

7 What to Expect After Submitting Your Dual/Joint Enrollment Application Motlow College Application Status You will begin to receive correspondence from Motlow College as soon as your Dual/Joint Enrollment Application Packet has been processed. This correspondence will include: Letter containing your Motlow College ID number (also called your A number) Notice alerting you if any items are missing from your application packet Instructions for accessing your MyMotlow account, including accessing your Motlow College account (you are responsible for remembering your MyMotlow login information) Dual Enrollment Grant Application Status Your Dual Enrollment Grant Application Status on the Tennessee Student Assistance Corporation (TSAC) website will remain as Pending Verification until it has been processed and your enrollment verified by Motlow College. Generally, this will not occur until after the Dual Enrollment Grant Application deadline stated on the TSAC website. You must re-apply for the Dual Enrollment Grant each semester. Please review the enclosed the appropriate Dual Enrollment Grant Frequently Asked Questions document for details regarding grant eligibility and amounts. Please note that for , your high school grade level will determine how the Dual Enrollment Grant is awarded. Enrollment in Class(es) Students must coordinate their registration requests through their high school counseling office to ensure proper course selection and application of credits. If you will be taking a Motlow College class arranged by your high school, your high school counselor will provide Motlow College with a list of students to enroll. If you will be taking a Motlow College class not arranged by your high school, you will enroll yourself through your MyMotlow account. Please contact your guidance counselor if you are unsure of whether you will need to enroll in your class. Payment for Class(es)/Fees Please see above for information regarding the Dual Enrollment Grant. Your balance will be reflected on your MyMotlow account. If your balance appears incorrect on your MyMotlow account, this is either because your grant application has not been processed, you have not applied for the grant, or your collegiate GPA has dropped below a Starting a class and subsequently dropping it after classes begin will not result in a full refund. Payments will be due on the Dual Enrollment payment date listed on the Motlow College Calendar. Fees can be paid at any Motlow College campus. They can also be paid online or by phone with a credit card (MasterCard, Visa, American Express, or Discover). Textbook Costs Students are responsible for obtaining all required textbooks for their Motlow College course(s). Depending on the course, students may be able to purchase or rent new, used or digital textbooks. You may find all textbook information for your courses from the on-campus Motlow College Follett Bookstore or online at If you choose to obtain your textbooks from another vendor, it is your responsibility to ensure you obtain the correct edition

8 Dates to Remember For important dates for each semester, reference the calendar for that semester. The calendars can be accessed at Dropping Classes Students are not permitted to drop their dual enrollment classes without consulting with their high school counselor. Dropping a class after classes begin will not result in a full refund, and may result in future academic consequences. Grading Motlow College will issue a letter grade to each student. Numerical grades will be used for high school purposes. Considering the difference in grading scales, individual high schools may adjust the numeric average to obtain a weighted score. The highest possible grade is 100. Students may obtain grades for the current term by logging on to Motlow College s website at Click on MyMotlow then: 1. Click Student Login 2. Enter User ID and PIN a. User ID is your A number b. PIN is the number you originally listed on your application (unless later changed by student) 3. Click Student Records 4. Click Academic Transcript Grades will be available each term on the third weekday after final exams. Transcripts will be provided to your high school. Students may request a printed copy of the transcript in writing from the Admissions and Records Office. In all cases, a student's obligations to the college must be fulfilled before a transcript will be issued. Tutoring If you need help with a Motlow College course, help may be available. Motlow College subscribes to a 24/7 online academic support service called Smarthinking. This can be accessed from Motlow College s website. Click on the Current Student tab for the link. Transitioning from a MSCC Dual/Joint Enrollment student to a traditional MSCC College Student Upon graduation, dual enrollment students should complete a New Incoming Freshman Admissions Application. The application fee should not be paid again. Motlow will also need a copy of your final high school transcript with your graduation date listed. Motlow State Community College courses are easily transferable to Tennessee Board of Regents institutions. It is the student s responsibility to verify the transferability of courses to his or her future institution and intended major. What to Expect, pg

9 Dual/Joint Enrollment Checklist Determine your academic eligibility Completed 10 th grade For a collegiate mathematics or science course: o ACT/ACT Plan Reading sub-score of 19 or greater, and o ACT/ACT Plan Writing sub-score of 18 or greater, and o ACT/ACT Plan Mathematics sub-score of 19 or greater For any other collegiate course (non-mathematics or non-science): o ACT/ACT Plan Reading sub-score of 19 or greater, and o ACT/ACT Plan Writing sub-score of 18 or greater The COMPASS test may be used to challenge the ACT scores (not PLAN ACT scores). You can sign up for the test at Complete the Motlow College Dual/Joint Application for Admission Packet by the posted application deadline. Complete and sign Dual/Joint Application for Admission (student signature in ink is required). Your Social Security Number is required to verify your dual enrollment grant. Effective April 1, 2015, Motlow College no longer assesses an Application Fee. Complete and sign the Signature Page for Web Applicant and Tennessee Eligibility Verification for Entitlement Agreement and provide a copy of your driver s license or birth certificate as proof of citizenship. If you are a full-time student (taking 12 or more academic credits in a semester/term), you must provide proof of two varicella (chicken pox) shots administered on or after the first birthday, or proof that you had the disease. This is a requirement for college that was not required for you to attend high school. Include an official copy of your high school transcript with your current GPA and ACT scores included. You can get this from the Counseling Office at your high school. Although there is no longer a minimum GPA required for enrollment, this information is required to verify your dual enrollment grant eligibility. Review the Tennessee Dual Enrollment Grant Rules and Procedures located at: Additional information can be found on the Dual Enrollment Grant Frequently Asked Questions contained in this packet. Complete the online Tennessee Dual Enrollment Grant Application (link located at Check the Motlow College calendar located at for the semester in which you plan to/are enrolled for important deadlines. You are responsible for these deadlines! Attend a mandatory orientation session in August before classes begin. The exact date will be communicated to you through your guidance counselor. Pay your remaining fees by the Dual/Joint Enrollment payment due date as stated on the Motlow College calendar for the semester in which you are enrolled. Please note: If your parent/guardian is a Tennessee public school teacher or a state employee, you may be eligible for discounted fees. Please ask your parent/guardian to see his/her Human Resources Office for the appropriate form

10 Fax: A Tennessee Board of Regents Institution DUAL/JOINT ENROLLMENT APPLICATON FOR ADMISSION Effective April 1, 2015, Motlow College no longer assesses an Application Fee. Applicants must complete every item on this form in BLUE or BLACK ink, sign, date, and return to: HS Partnership Programs, Dept. 265 P.O. Box 8500 Motlow State Community College Lynchburg, Tennessee SOCIAL SECURITY NUMBER (XXX-XX-XXXX): - - Your dual enrollment grant cannot be verified without this information. MSCC ID: FULL LEGAL NAME: Miss Mr. Mrs. Ms. Last First Middle Former PERMANENT HOME ADDRESS: City: State: Zip: PHONE NUMBERS: County of Permanent Address: Home: ( ) - Address: Cell: ( ) - Marital Status: Single Married Work: ( ) - MAILING ADDRESS: City: State: Zip: Your completion of the following questions is requested for reporting purposes only. This information will not be used to discriminate against any applicant in the admissions decision process. DATE OF BIRTH: Month Day Year GENDER: Female Male Do you consider yourself to be Hispanic/Latino/Spanish origin? Yes No In addition, select one or more of the following categories to describe yourself: White Black or African American Asian American Indian Alaskan Native Native Hawaiian or Other Pacific Islander HAVE YOU LIVED IN TENNESSEE CONTINUOUSLY FOR THE PAST TWELVE (12) MONTHS? Yes No Date moved to TN: IF NO, WHERE? City: State: Zip: CHECK ONE: U.S. Citizen Foreign Citizen, non-immigrant Foreign Citizen, permanent U.S. resident If non-u.s. resident, in what country do you hold citizenship? In what country were you born? What type visa do you hold? What is your native language? English Other (specify) All male citizens of the United States of America born in 1960 or thereafter must have registered for the draft prior to registering for classes at Motlow College. This requirement does not apply to veterans and others exempt by federal law. Indicate whether or not you have registered for the United States draft. Yes No I am not yet 18 Exempt PARENTS/GUARDIAN (person to notify in case of emergency): NAME (Last): (First): (Middle): RELATIONSHIP: ADDRESS No. and Street: Phone: ( ) - City: State: Zip: CURRENT HIGH SCHOOL: EXPECTED GRADUATION MONTH/YEAR: Home-schooled student, list affiliate school or district with which you are registered: LIST BELOW ANY COLLEGE OR UNIVERISTY WHERE YOU MAY HAVE TAKEN DUAL ENROLLMENT COURSES. *(FAILURE TO DO SO WILL VOID APPLICATION.) Name/Location of Institution Dates Attended (Month/Year) Name Under Which Transcript Will Be Used Semester and year you plan to begin Dual/Joint Enrollment with Motlow State Community College: Fall 20 Spring 20 Summer 20 I certify that all of the information on this application form is true to the best of my knowledge and that no information has been intentionally withheld. I also agree to furnish Motlow State Community College with official copies of transcripts, placement test scores and/or ACT scores. My acceptance at Motlow State Community College is based upon receipt of these documents. Student Signature: Date: Student must create a personal identification number (PIN) that is 6 digits (numbers). Please remember this PIN because it will be used for all Motlow online activities (MyMotlow,D2L, etc.). PIN #:

11 Dual Enrollment Form First time dual enrollment students must complete an official college admission application and this form to be eligible. 1. To Be Completed by Student Name: SSN: High School: Grade Level: *Age: * If 18 or over, proof of US citizenship is required. A valid driver s license will suffice for this information. 2. To Be Completed by High School Counselor/Principal Please Circle One: ACT ASPIRE PLAN COMPASS English Math Reading Composite Month Year Counselor/Principal s Signature Date: 3. To Be Completed by Student I understand by becoming a Dual Enrollment student, I must abide by the high school s and the college s rules and regulations. In acknowledgement of the Family Educational Rights and Privacy Act of 1974 (FERPA), I give Motlow State Community College permission to release any information regarding my grades, attendance, academic standing, disciplinary action, financial obligations, or any other aspect of my student life to my parents or legal guardians while I am a dual enrollment student. I understand grades, attendance, and any other academic information will be provided to the high school as part of this agreement. Student s Signature: Date: 4. To Be Completed by Parent/Guardian Applications for the TN Dual Enrollment Grant must be submitted online for each semester funds are requested. You may access the TN dual enrollment grant at A TN Additional Courses Acknowledgment Form posted on the TSAC website must be submitted with registration to receive the award. I have submitted my Dual Enrollment Grant application online at the above website. I do not wish to receive funds from the Dual Enrollment Grant. Please be aware once you exceed $1200 from the Dual Enrollment Grant Awards, the additional funding will be deducted from the first semester HOPE scholarship award, if desired. Please check one of the following: If I exceed the $1200 allowed from the Dual Enrollment Grant, I DO want to deduct from the first semester of my HOPE scholarship. If I exceed the $1200 allowed from the Dual Enrollment Grant, I DO NOT want to deduct from the first semester of my HOPE scholarship. Please be aware IN ADDITION TO completing the online TN Dual Enrollment application each semester, your student MUST submit a Dual Enrollment Grant Program Authorization Form each semester if taking more than one dual enrollment course in a single semester. Please note you are responsible for the cost of textbooks. Legal Parent/Guardian Parent s Signature: Parent s FOR OFFICE USE ONLY

12 Hepatitis B Immunization Health History Form All Students Must Complete The General Assembly of the State of Tennessee mandates each public or private postsecondary institution in the state provide information concerning hepatitis B infection to all students matriculating for the first time. Tennessee law requires such students complete and sign a waiver form provided by the institution that includes detailed information about the disease. The law does not require students receive vaccination for enrollment. Furthermore, the institution is not required by law to provide vaccination and/or reimbursement for the vaccine. Hepatitis B (HBV) Immunization 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 transmitted by blood and/or body fluids and many people will have no symptoms when they develop the disease. The primary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease is completely 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 optimal protection. Missed doses may still be sought to complete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases. I hereby certify that I have read this information and I have had the entire series of the Hepatitis B vaccine. I hereby certify that I have read this information and I have elected not to receive the Hepatitis B vaccine. I hereby certify that I have read this information and I have elected to receive the Hepatitis B vaccine and/or I am in the process of receiving the complete three dose series of the Hepatitis B vaccine. Parent Signature Student may sign if over the age of 18. Date I understand withholding information on this application or giving false information may make me ineligible for admission to, or continuation in Motlow State Community College. Accordingly, I certify all of the information and statements provided by me on this application are correct and complete. Further, if I am admitted to Motlow State Community College, I agree to abide by the rules and regulations of the institution. In addition to the forgoing, the Tennessee Eligibility Verification for Entitlements Act requires an applicant for in-state tuition or state financial aid to attest under penalty of perjury that he or she is either a United States citizen or alien lawfully present in the United States. By submitting this application, I am attesting I am either a United States citizen or alien lawfully present in the United States or I am not requesting any state benefits including in-state tuition. I understand this attestation is required by Tennessee law if I have applied for a state public benefit. I understand Tennessee law requires me to provide documentation verifying the status indicated above prior to receipt of this state public benefit. I understand knowingly and willfully making a false, fictitious, or fraudulent statement or representation shall subject me to liability under the Tennessee False Claims Act, Tennessee Code Annotated et seq. I understand if I am found to have made a false or misleading statement, my state public benefits may be rescinded or I may be disciplined by the college. Student s Signature Student s Printed Name Student s SSN Date

13 Tennessee Eligibility Verification Agreement The Tennessee Eligibility Verification for Entitlements Act (EVEA) requires for instate tuition or state financial aid an applicant to attest under penalty of perjury that he or she is either a United States citizen or alien lawfully present in the United States. By submitting this application, I am attesting that I am either a United States citizen or alien lawfully present in the United States or I am not requesting any state benefits including in state tuition. I understand that this attestation is required by Tennessee law if I have applied for a state public benefit. I understand that Tennessee law requires me to provide documentation verifying the status indicated above prior to receipt of this state public benefit. I understand that knowingly and willfully making a false, fictitious, or fraudulent statement or representation shall subject me to liability under the Tennessee False Claims Act, Tennessee Code Annotated et seq. I understand that if I am found to have made a false or misleading statement my state public benefits may be rescinded or I may be disciplined by the college. I understand that documentation will be required. (See attached list for approved documentation.) Printed Name Signature Date

14 Important College Information The Tennessee Eligibility Verification for Entitlement Act (EVEA) became effective on October 1, The EVEA requires state public institutions of higher education to verify that persons seeking a state public benefit are either a United States citizen or lawfully present in the United States. For students claiming U.S. citizenship the student will need to provide a copy of one (1) of the following documents: A valid regular Tennessee driver s license; A temporary Driver License or Temporary Identification License is NOT acceptable. A valid regular driver s license from another state (except for Utah and New Mexico); An official birth certificate issued by a U.S. state, jurisdiction, or territory, except for Puerto Rican birth certificates issued before July 1, 2010; A U.S. government issued certified birth certificate; A valid, unexpired U.S. passport; A U.S. certificate of birth abroad (DS-1350 or FS-545); A report of birth abroad of a citizen of the U.S. (FS-240); A certificate of citizenship (N560 or N561); A certificate of naturalization (N550, N570, or N578); A U.S. citizen identification card (I-97, I-179) Students claiming to be a qualified alien who is lawfully present in the United States, must verify their Alien Registration Number (A#) or I-94 Admissions Number by: U.S. permanent residents (individuals with an I-151, I-551, or I551C permanent resident card); and Individuals who have an Arrival/Departure Record (I-94) showing one on the following designations: Refugee; Asylum granted; Cuban-Haitian Entrant (Status Pending); Conditional Entrant (Valid only if issued before April 1, 1980); Victims of Human Trafficking (T-2, T-3, or T-4 visa); or Parolee (who meets certain conditions) OR Presenting two (2) forms of documentation establishing lawful presence in the United States. Valid regular Tennessee driver s license; A temporary Driver License or Temporary Identification License is NOT acceptable. Valid, unexpired Foreign Passport with visa stamped Processed for I-551 ; Permanent Resident Re-Entry Permit (I-327); Refugee Travel Document (I-571); Employment Authorization Document (Form I-766); Valid, unexpired Foreign Passport with valid visa; If none of the above documentation can be provided, please contact the Admissions office

15 Dual Enrollment Grant Program Authorization Academic Year JUNIORS ONLY Student s Full Legal Name (please print) Name of High School Student s Social Security Number (required for grant verification) Students must complete the online Dual Enrollment Grant application and this form for each semester if taking more than one Dual Enrollment course. For ALL STUDENTS during : Students must apply for the Dual Enrollment Grant each academic semester by completing the online application at and by completing and returning this form to Motlow College by the deadline listed on the Tennessee State Assistance Corporation website listed above. Student awards will be limited to no more than two (2) courses for each academic term. Students wishing to receive grant awards for two dual enrollment courses in the same academic term must have a minimum 21 ACT Composite (980 SAT) or minimum 3.0 High School GPA. Home school students must have a minimum 21 ACT Composite (980 SAT). Students must maintain a minimum 2.75 college GPA to continue grant eligibility. The maximum award for the Dual Enrollment Grant shall be $1200 per academic year. For JUNIORS during (Class of 2017): Effective with the academic year, entering JUNIORS may be eligible for the following dual enrollment grant award amounts: o FIRST Course: Up to $500 o SECOND Course: Up to $500 (will NOT reduce HOPE if used during same term as 1 st or 3 rd Course award) o THIRD Course: Up to $200 o FOURTH Course: No award o Courses FIVE through EIGHT: $100 per credit hour (deducted from HOPE) I will be a High School Junior during the academic year and will be enrolled in the Dual Enrollment Program with Motlow College. I have applied for a Dual Enrollment Grant, and I understand that I may be eligible to receive a second grant award during the same academic term. I choose to use the dual enrollment grant for two courses during the following academic term listed below. I understand receipt of the second grant for courses 5 through 8 will reduce my HOPE Scholarship award. (choose all that apply): Fall 2015 Spring 2016 Summer 2016 I choose to use the dual enrollment grant for only ONE course during the academic term listed below: (choose all that apply): Fall 2015 Spring 2016 Summer 2016 Student Signature (use legal name only) Parent Signature (required) Date Signed Date Signed Parent s Printed Name

16 Dual Enrollment Grant Program Authorization Academic Year SENIORS ONLY Student s Full Legal Name (please print) Name of High School Student s Social Security Number (required for grant verification) Students must complete the online Dual Enrollment Grant application and this form for each semester if taking more than one Dual Enrollment course. For ALL STUDENTS during : Students must apply for the Dual Enrollment Grant each academic semester by completing the online application at and by completing and returning this form to Motlow College by the deadline listed on the Tennessee State Assistance Corporation website listed above. Student awards will be limited to no more than two (2) courses for each academic term. Students wishing to receive grant awards for two dual enrollment courses in the same academic term must have a minimum 21 ACT Composite (980 SAT) or minimum 3.0 High School GPA. Home school students must have a minimum 21 ACT Composite (980 SAT). Students must maintain a minimum 2.75 college GPA to continue grant eligibility. The maximum award for the Dual Enrollment Grant shall be $600 per semester ($1200 per academic year). For SENIORS during (Class of 2016): During the academic year, SENIORS may be eligible for the following dual enrollment grant award amounts: o Courses ONE through FOUR (including courses taken as a Junior): Up to $100 per credit hour o Courses FIVE through EIGHT: $100 per credit hour (deducted from HOPE) I will be a High School Senior during the academic year and will be enrolled in the Dual Enrollment Program with Motlow College. I have applied for a Dual Enrollment Grant, and I understand that I may be eligible to receive a second grant award during the same academic term. I choose to use the Dual Enrollment Grant for two courses during the following academic term listed below. I understand receipt of the second grant may reduce my HOPE Scholarship award. (choose all that apply): Fall 2015 Spring 2016 Summer 2016 I choose to use the dual enrollment grant for only ONE course during the academic term listed below: (choose all that apply): Fall 2015 Spring 2016 Summer 2016 Student Signature (use legal name only) Date Signed Parent Signature (required) Date Signed Parent s Printed Name

17 PLEASE SEND ALL DUAL/JOINT ENROLLMENT APPLICATION MATERIALS TO THE APPROPRIATE ADDRESS LISTED BELOW: Motlow College Mrs. Lori Mevis High School Partnership Program Specialist P.O. Box 8500 Lynchburg, TN Serving students in Bedford, Coffee, Franklin, Moore, and Rutherford Counties Motlow College Mrs. Laura Monks Director, Fayetteville Center 1802 Winchester Hwy Fayetteville, TN Serving students in Franklin and Lincoln Counties Motlow College Mrs. Melody Edmonds Director, McMinnville Center 225 Cadillac Lane McMinnville, TN Serving students in Cannon, DeKalb, Van Buren, Warren and White Counties IMPORTANT REMINDER ABOUT THE DUAL ENROLLMENT GRANT Students MUST apply for the Dual Enrollment Grant by the deadline noted on the Tennessee Student Assistance Corporation website each semester if they wish to receive funds. For more information, go to: