Middle College 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.
_____ I am a new dual enrollment student.
_____ I am a returning dual enrollment student. (You must have a college GPA of at least 2.75 to receive grant.)
1. To Be Completed by Student
2. To Be Completed by the High School Counselor/Principal
Name ____________________________________________________
First
MI
Last
SS# ______________________________________________________
Student's GPA ______________________ Scale
Address __________________________________________________
Will the student be receiving high school credit for this/these course/s?
______ Yes ______ No
City ______________________________ Zip Code _______________
Phone ___________________________ Birth date _______________
Alternate Phone ____________________________________________
Email ____________________________________________________
High school ________________________________________________
Grade level __________________________ Age _________________
If currently enrolled in dual enrollment at another institution,
please list college: _______________________________________
Please circle one:
r 4.0
ACT or PLAN
____ English ____ Math ____ Reading ____ Science ____ Composite
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.
Signature ________________________________________________
Date ____________________________________________________
3. To Be Completed by the Student and Parent
Applications for the TN Dual Enrollment Grant must be submitted online for each term
funds are requested. You may go to www.roanestate.edu/dualstudiesto 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.
If not currently enrolled but did enroll at another institution in the past,
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.
please list college: _______________________________________
By signing this document, I agree I:
_______________________________________________________
_______________________________________________________
REQUIRED TO ENROLL IN CLASS
Semester and Year r Spring r Summer r Fall
Year _______________
Course Prefix
example
PSYC
Course No.
Section No.
CRN (if known)
1010
BO1
83042
• 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.
- - - - - - - - - - - - - - - - - - - - - and - - - - - - - - - - - - - - - - - - - - - - Please check one of the following:
__________ Option 1
__________ Option 2
__________ Option 3
1. ______________________________________________________
__________ I do not wish to request any money
from the Dual Enrollment Grant.
2. ______________________________________________________
I understand that I am fully responsible for the full amount of tuition/fees.
3. ______________________________________________________
Student's Signature ______________________________________________
4. ______________________________________________________
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
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 #16-063.