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.
_____ 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.)
2. To Be Completed by the High School Counselor/Principal
1. To Be Completed by Student
Name ____________________________________________________
First
MI
Last
SS# ______________________________________________________
Student's GPA ______________________ Scale
Please circle one:
r 4.0
ACT or PLAN
Address __________________________________________________
____ English ____ Math ____ Reading ____ Science ____ Composite
City ______________________________ Zip Code _______________
Will the student be receiving high school credit for this/these course/s?
Phone ___________________________ Birth date _______________
______ Yes
Alternate Phone ____________________________________________
Email ____________________________________________________
High school ________________________________________________
Grade level __________________________ Age _________________
If currently enrolled in dual enrollment at another institution,
please list college: _______________________________________
_______________________________________________________
If not currently enrolled but did enroll at another institution in the past,
please list college: _______________________________________
_______________________________________________________
REQUIRED TO ENROLL IN CLASS
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/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
$600 award.
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 $300 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:
Course No.
Section No.
CRN (if known)
•have read the guidelines.
•have given appropriate college and high school administrators permission
1010
BO1
83042
•have given my permission to my high school administration to release my SPRING SEMESTER 2015
Course Prefix
example
PSYC
______ No
1. ______________________________________________________
to discuss my Roane State records while participating in dual enrollment.
high school transcript/records to Roane State Community College.
- - - - - - - - - - - - - - - - - - - - - and - - - - - - - - - - - - - - - - - - - - - - Please check one of the following:
_____ $300 for 1 class
2. ______________________________________________________
_____ $300 for 2 classes
_____ $600 for 2 classes
_____ I do not wish to request any money from the Dual Enrollment Grant.
I understand that I am fully responsible for the full amount of tuition/fees.
3. ______________________________________________________
4. ______________________________________________________
Student's Signature ______________________________________________
Date __________________________________________________________
Parent's Printed Name ____________________________________________
Signature _______________________________________________________
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 #12-031b.