Re-Registration Dual App 3-10 FSCJ

Dual Enrollment Program Permission to Re-register
Application for Returning Dual Enrollment Students Only
College Use Only Student Special Designator:
Teacher Name: ______________________
PERSONAL INFORMATION
Last
Please print in ink and complete in full.
Name_______________________________________________________________________ ____________________
First Middle County
Social Security or College ID Number____________________________ Telephone (
)______________________
*In compliance with Florida Statute 119.071(5), Florida State College at Jacksonville issues this notification regarding the purpose of the collection and use of Social Security numbers. Florida State College will collect your Social Security Number (SSN) for record identification, state and federal reporting. Providing your SSN on this application means that you consent to the use of your number in the manner described. If you choose not to provide your SSN, you will be provided an alternate identification number. All Social Security Numbers are protected by Federal regulations and are not to be released to unauthorized parties. Read more about the collection and use of social security numbers (http://www.fscj.edu/ssn).
Mailing Address ___________________________________________________________________________________

Number and Street or P.O. Box Apt. #
________________________________________________________ E-Mail ___________________________________

City State ZIP Code
ENROLLMENT PLANS
Name of high school ____________________City _____________ Anticipated graduation date: Month ____Year___
Dual Enrollment course(s) for which this application is intended:
Term
College Course #
Ref. #
Course Title
Location of Class
Check all high school mathematics course(s) that you have completed to date. (Mark all that apply.) __________ a. Algebra I __________ b. Algebra II __________ c. Geometry __________ d. Trigonometry __________ e. Calculus or Pre-Calculus
HIGH SCHOOL PERSONNEL AGREEMENT
To be completed by School Officials
Name of Applicant __________________________________________________________________________________ is enrolled at _________________________________ High School in __________________________ County, which has a dual enrollment contract with Florida State College at Jacksonville. This individual meets the established weighted grade point average (GPA) and high school classification criteria, and I recommend that he/she be enrolled in the course(s) listed above. Mark items attached: Transcripts and GPA
PLEASE ATTACH FULL TRANSCRIPT OR ACADEMIC HISTORY WITH CURRENT CUMULATIVE GPA.
Applications without the appropriate attachments will be returned.
High School Counselor Name (please print) _________________________________________________ High School Counselor Signature_____________________________________________________ Date _____________ Counselor e-mail address__________________________________________ Phone number ______________________
Please continue on reverse side of form.
(March 2010, white form)
PARENT/GUARDIAN AGREEMENT
To be completed by Parent/Guardian
Name of Applicant: __________________________________________ has my permission to enroll at Florida State College in the dual enrollment program. I understand that credit will be provisional until he/she earns a high school diploma. I also give permission to Florida State College at Jacksonville to release his/her academic record from the high school named in this contract. Parent/Guardian Signature __________________________________________________ Date ____________________
STUDENT AGREEMENT
To be completed by Student
I hereby apply for admission to Florida State College at Jacksonville and agree to abide by all rules and regulations of the College. I authorize release of my academic record to the high school named in this application. I understand that Florida State College at Jacksonville will not release official transcripts to any other schools/organizations until verification of high school graduation is received and the Record Change Form is completed to change my admission status. I understand that to continue enrollment at Florida State College at Jacksonville after graduation, I must submit a Record Change Form to change my admission status. I have checked this application for error and certify that the information is accurate and complete. Applicant Signature _________________________________________________________ Date ___________________

Re-Registration Dual App 3-10 FSCJ

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Re-Registration Dual App 3-10 FSCJ

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Dual Enrollment Program Permission to Re-register

Application for Returning Dual Enrollment Students Only

College Use Only Student Special Designator:

Teacher Name: ______________________

Please print in ink and complete in full.

Social Security or College ID Number____________________________ Telephone (

Mailing Address ___________________________________________________________________________________

______________________ E-Mail _

HIGH SCHOOL PERSONNEL AGREEMENT

To be completed by School Officials

Applications without the appropriate attachments will be returned.

Please continue on reverse side of form.

(March 2010, white form)

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