Dual Enrollment Course
Registration Form
ROANE STATE
COMMUNITY
COLLEGE
Procedures
• First time dual enrollment students must complete a college admission application at www.roanestate.edu/dualstudies prior to registering for classes.
• This course registration form must be completed every semester in order to enroll in courses as a dual enrollment student.
r
r
New dual enrollment student
Returning dual enrollment student
r
r
Currently enrolled at another institution. List college__________________________________
Not currently enrolled, but did enroll in the past. List college___________________________
1. To Be Completed by Student
3. To Be Completed by the Student and Parent
Name ____________________________________________________
First
MI
Last
SS# ______________________________________________________
Applications for the TN Dual Enrollment Grant must be submitted online
for each term funds are requested. You may go to www.roanestate.edu/
dualstudies to access the TN Dual Enrollment Grant link. A TN Additional
Courses Acknowledgement Form posted on the Tennessee Student
Assistance Corporation website must be submitted with the registration
to receive the award.
Address __________________________________________________
City ______________________________ Zip Code _______________
Phone ___________________________ Birth date _______________
Alternate Phone ____________________________________________
Email ____________________________________________________
High school ________________________________________________
Grade level __________________________ Age _________________
r Spring
Course Prefix
r Summer
Course No.
r Fall
Section No.
Year ___________
Please be aware that once a student exceeds $1200 from the Dual
Enrollment Grant awards, the additional funding will be deducted from
the first semester HOPE scholarship award. In other words, the first four
dual enrollment awards do not affect the HOPE scholarship. Once a dual
enrollment student accesses Dual Enrollment Grant funds for a 5th class,
deductions will be applied to future HOPE scholarship accounts.
By signing this document, I agree I:
•have read the guidelines.
•have given appropriate college and high school administrators
permission to discuss my Roane State records while participating in
dual enrollment.
•have given my permission to my high school administration to release
my high school transcript/records to Roane State Community College.
The Tennessee Student Assistance Corporation provides a Dual Enrollment
Grant in the following formula;
CRN (if known)
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________
Max of $1000/semester not to exceed $1200/year.
Please check all that apply:
r $500 (1st class)
r $500 (2nd class) must be HOPE eligible if taking 2 classes/
same semester
r $200 (3rd class)
r
2. To Be Completed by the High School Counselor/Principal
Student's GPA ______________ Scale
r 4.0 r ACT r PLAN
____ English ____ Math ____ Reading ____ Science ____ Composite
Will the student be receiving high school credit for this/these course/s?
______ Yes ______ No
$0 (4th class)
Beginning with the 5th class, students can draw from the HOPE Scholarship
at $100/per credit hour (max of $600/per semester / $1200/per year).
Deductions will be applied to future HOPE Scholarship amounts.
Do you wish to use the Dual Enrollment Grant?
r Yes
r No
Do you wish to use HOPE Scholarship (5th class)? r Yes
r No
If so, please check the amount you are borrowing
from HOPE:
r $300
r $600
I believe this student has the ability to benefit from college instruction
and has the ability to conduct himself/herself in a manner consistent
with college-level expectations.
I understand that I am fully responsible for the full amount of tuition/fees.
Signature _________________________________ Date ___________
Parent’s Printed Name___________________________________________
FOR OFFICE USE ONLY
r Yes
r No
GPA meets requirement ____________
r Yes
r No
Hepatitis B Form
r Yes
r Yes
r No
r No
Student’s Signature__________________________ Date_______________
Transcript received
ACT/PLAN scores met
Please circle one: ACT or PLAN
R Number ___________________________
RSCC GPA __________________________
Roane State is a TBR and AA/EEO employer and does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs and activities. The following person has been designated
to handle inquiries regarding the non-discrimination policies: Director of Human Resources/Affirmative Action, 276 Patton Lane, Harriman, TN 37748, (865) 882-4679. RSCC is a Tennessee Board of Regents
Institution and an AA/EEO Institution. RSCC Publication #16-064.