Dual Enrollment Application Creation

MUW Dual Enrollment/Credit Application & Course Request Form

Section 1: Student Information

Student First Name *

Student Last Name *

Student Personal Email Address *

Student School Email Address
(please only provide your school-provided email address here)

Student Cell Phone *

Student Birthdate *

SSN *

Permanent Address *

Country

Street

City

Region

Postal Code

Section 2: School and Academic Information

Will you be attending the Mississippi School for Mathematics and Science? *

Are you homeschooled? *

Are you a part of the ECHO (East Columbus Homeschool Organization)? *

Current High School *

School Name *

Provide your dual enrollment clerk or counselor's first name *

Provide your dual enrollment clerk or counselor's last name *

Provide your dual enrollment clerk or counselor's email *

Grade Level *

Anticipated Graduation Date *

School Clerk or Counselor Disclosure *

I consent to the disclosure of any personally identifiable information from my education records to my school counselor, for reasons determined by MUW as appropriate. This authorization will remain in effect for the academic school year.

Yes, I consent to disclose information to my school counselor.

College Level Coursework

Have you completed or will you be completing college-level coursework prior to entering The W? College-level work can be defined as dual-enrolled courses, AP exams, or college courses. *

Yes

Please note: Prior to your course registration, we will need official documentation such as a transcript sent to the registrar's office to acknowledge the college credit.

Section 4: Parent Information

Parent #1 Type *

Parent #1 First Name *

Parent #1 Last Name *

Parent #1 Email *

Do you want to add a second parent's information? *

Parent #2 Type (optional)

Parent #2 First Name (optional)

Parent #2 Last Name (optional)

Parent #2 Email (optional)

Parent Disclosure *

I consent to the disclosure of any personally identifiable information from my education records to my parent(s) listed above, for reasons determined by MUW as appropriate. This authorization will remain in effect for the academic school year.

Yes, I consent to disclose information to my parents.

Section 5: Certification

Certification *

By typing my name below (in place of a legal signature), I agree to participate in the listed dual enrollment/credit program at Mississippi University for Women, and I understand that I am responsible for payment of any charges that are not covered by MUW scholarship as agreed upon by the school district and MUW. I understand that I must abide by any and all policies and rules set forth by MUW.

I authorize the Registrar's Office at Mississippi University for Women to send final grades earned during dual enrollment at the end of each semester to my high school. I understand the final grades will display on my official MUW transcript.

Student Name

Date

Dual Enrollment Application Creation

MUW Dual Enrollment/Credit Application & Course Request Form

Office of Admissions

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