DUAL ENROLLMENT REGISTRATION
(Please Print Clearly)
3
College ID (Required):
Legal Last Name:
First:
Middle:
Mailing Address:
City:
Email:
Date of Birth:
Home Phone: (
)
-
Alternate Phone: (
State:
Zip:
/
/
)
(STAFF USE ONLY) Course prerequisites
Grade Level (circle one): 9th 10th 11th 12th
High School:
COURSE
CLASS #
PERIOD
INSTRUCTOR
CREDITS
COST
(Ex: ENG101)
(Ex: 12345)
(Ex: 4th)
(Ex: Johnson)
(Example: 3)
$76/credit hour*
Registra on Fee
$15
TERM
YEAR:
Fall
Spring
Applying for Tui on Assistance?
N
A
Course or Test Name
A
S
A
P
Test
Score
*Based on in-county residency tui on
rate. See the course table for your
school for more informa on.
Total Cost
Students Applying for Tui on Assistance
sa slZed by course or test score. Enter
N/A, course, or test score as needed.
AS = ASSET and AP = ACCUPLACER
YES
No
Received date:
If you are applying for tuition assistance, we will hold the enrollment packet un l the status of the application has been determined. If tuition assistance is not
awarded or available, please indicate your choice:
Do not enroll me
Enroll me anyway
Contact me
Contact telephone #
Contact e-mail:
STUDENT SIGNS HERE:
I cer fy that the informa on on this enrollment form is true and complete, and I understand that PC cannot release informa on about my enrollment, fees or
grades to my parents and /or guardian(s) unless I list them here. (To receive informa on, these individuals must know my College Student ID.)
Student Signature
Printed Names of Parents /Guardians:
Date
PARENT SIGNS HERE:
As parent or legal guardian, I give permission for the above-named student to enroll in the courses listed, and I accept financial responsibility for tuition, fees and textbooks.
I acknowledge that all tui on and fees are owed once this form is submi t t ed and that tui on and fees are due on or before Friday, February 6, 2014.
I have read the
informa on provided and understand that the above named student will be establishing a college academic record and will be required to report such enrollment to future
colleges or universiti es. He/she will be subject to all of the requirements, policies, regula ons, and deadlines delZned in the dual enrollment paperwork provided, the College
Catalog, the Schedule of Classes and the Student Handbook and that this informa on can be accessed via the Phoenix College Dual Enrollment website:
www.pc.maricopa.edu/pcdt/dual
Parent/Guardian Signature
Parent Email
HIGH SCHOOL OFFICIAL SIGNS HERE:
Under 18 Admissions qualification: students must meet one of the following:
PSAT ≥ 93
SAT ≥ 930
ACT ≥ 22
AIMS Test scores: Reading ≥ 674
Writing ≥ 678
Math ≥ 683
College Placement Test: ACCUPLACER Score:
Supporting documentation
Transcript a ached
Test Scores a ached
I have reviewed the informa on on this form, and the student is eligible to participate in these dual enrollment courses.
Signature of High School Official
Date
A.R.S. 15-901 requires students to be currently enrolled at the school for a full me instruc onal program in addi on to the college course.
NOTE: High school seniors who sa sfy high school gradua on requirements are exempt.
For more informa on : www.pc.maricopa.edu/pcdt/dual
White: College Copy
Yellow: PCDT Copy
Pink: Student Copy