Dual Enrollment Application

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 *

Gender *

Female

Male

Select your citizenship status *

U.S. Citizen

Permanent Resident/Resident Alien

Non-Resident Alien

Are you Hispanic/Latino *

Yes

Please indicate your race (check all that apply) *

SSN *

Permanent Address *

Country

Street

City

Region

Postal Code

Section 2: School and Academic Information

Current High School *

School Name *

Provide your school counselor's first name *

Provide your school counselor's last name *

Provide your school counselor's email *

School 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.

Anticipated Graduation Date *

Current High School GPA

Which standardized test have you/are you planning to take (check all that apply):

ACT

SAT

Both

None

ACT Date (if already taken)

ACT Composite Score

ACT English Score

ACT Math Score

ACT Reading Score

ACT Science Score

SAT Date (if already taken)

SAT Total Score

SAT Critical Reading

SAT Math

Section 3: Course Registration

Course 1: I am requesting to participate in dual enrollment/credit course(s) at MUW for the following term *

Course 1: What category of course are you looking to take? *

Course 1: What course would you like to take? *

Do you want to sign up for another course? *

Course 2: I am requesting to participate in dual enrollment/credit course(s) at MUW for the following term

Course 2: What category of course are you looking to take?

Course 2: What course would you like to take?

Do you want to sign up for another course?

Course 3: I am requesting to participate in dual enrollment/credit course(s) at MUW for the following term

Course 3: What category of course are you looking to take?

Course 3: What course would you like to take?

Do you want to sign up for another course?

Course 4: I am requesting to participate in dual enrollment/credit course(s) at MUW for the following term

Course 4: What category of course are you looking to take?

Course 4: What course would you like to take?

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.

Student Name

Date

Dual Enrollment Application

MUW Dual Enrollment/Credit Application & Course Request Form

Office of Admissions

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