Dual Enrollment - Dual Enrollment Student Information Form

05.26.13

All students who desire to take a dual enrollment course should complete this form prior to registering for a dual enrollment course.

Donna Smith, Dual Enrollment Coordinator dsmith@mail.lced.net

731 413-5253

Items denoted with a red asterisk * are required.

* Student's Last Name

* Student's First Name

* Student Cell Phone #

- -

(XXX)-XXX-XXXX

* Student Email Address

* School

* Graduation Year

* Race

* High School GPA

* College DE GPA

* Do you have a PLAN/ACT sub-score of at least 19 for the course area you are requesting

* College Course Requested

* 2nd College Course Requested

* If the course you requested is not available at your high school, can you arrange transportation and attend class at a college campus?

* Parent's/Guardian's Name

First Name

Last Name

Daytime Phone

- -

(XXX)-XXX-XXXX

* Parent Cell Phone Number

- -

(XXX)-XXX-XXXX

Text Authorizing

Yes No

Parent Email Address

Evening Phone

- -

(XXX)-XXX-XXXX

Questions regarding Dual Enrollment

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