# Dual/EMC Enrollment Authorization Form

This form is for course approval and tuition authorization only. Students need to register separately.

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| Type | PDF |
| Size | 84 KB |

[Open original PDF →](https://www.delta.edu/admissions/_documents/authorization-form-dual-enrollment.pdf)

## Document text

## Dual/EMC Enrollment Authorization Form

This form is for course approval and tuition authorization only. Students need to register separately.

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Delta College Dual Enrollment Office

dualenrollment@delta.edu  •  989-686-9428

## Office Use Only

Date:

Student #:

Initials:

Student First Name:

Last Name:

Birth Date:

/

/

Current grade:

Name of High School:

Check if home schooled

Anticipated Graduation Year:

Choose one:

Dual Enrollment

Early Middle College

Program:

## Student and Parent/Guardian Authorization Section

Students are responsible for managing their enrollment at Delta College. Dual enrolled students are expected to adhere to the rules and regulations in the Student Handbook.

-  I understand I am required to have authorization from my school prior to dual enrolling in a course. Therefore, payment for courses, tuition, fees, books, and supplies incurred by the student and not authorized by the high school will be the financial responsibility of the student and/or the parent/guardian. See Tuition and Fees Table for cost estimate.

-  I understand that enrollment is contingent upon timely completion of all requirements, I understand that some courses may contain mature topics and discussions. I understand that, if needed, withdrawal from courses is the responsibility of the student and could have financial consequences or an impact on my high school and/or college transcript.

-  Regardless of age, as a dual enrolled college student at Delta, your student information is protected by a federal law called the Family Educational Rights and Privacy Act of 1974 (FERPA). Therefore, college faculty and staff are not able to release or discuss academic information with parents/legal guardians. I understand student academic information is reported back to my high school and can be discussed with them.

Student Signature:

Date:

Parent/Guardian Signature:

Date:

## High School Authorization Section

Only needs to be completed if school is paying

A representative of the school district and or state approved nonpublic school has provided information to the student and parent/guardian on the Postsecondary Enrollment Options Act including enrollment eligibility, explanation of charges and any costs not covered by district, available support services, a reduced high school schedule, consequences of failing or not completing a postsecondary course, and the academic and social responsibilities assumed. Before enrolling, counseling services have been provided by the high school to ensure that the student and parent/guardian are fully aware of the benefits, risks, and possible consequences of enrolling in a postsecondary course including what courses count towards high school credit and how that credit will be applied to their high school transcript.

High School/District:

High School Representative Signature:

Date:

Billing should be directed to (School official responsible for billing):

Billing Contact:

Phone Number:

Email:

Fall

Winter (select one)

Spring   |   Year:

Fall

Winter (select one)

Spring   |   Year:

Fall

Winter (select one)

Spring   |   Year:

Please list courses (ex. ENG 111)

Please list courses (ex. COM 114)

Please list courses (ex. BIO 101)

## Payment

## Payment

## Payment

Note: Delta College will bill the district total cost, including books, unless indicated above.

District will pay total cost for tuition, fees and books.

District will pay total cost for tuition, fees and books.

District will pay total cost for tuition, fees and books.

District will pay all tuition and fees ONLY .

District will pay all tuition and fees ONLY .

District will pay all tuition and fees ONLY .

Self-pay, student is responsible for paying all tution and fees by payment deadline.

Self-pay, student is responsible for paying all tution and fees by payment deadline.

Self-pay, student is responsible for paying all tution and fees by payment deadline.

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<small>Source: [https://www.delta.edu/admissions/_documents/authorization-form-dual-enrollment.pdf](https://www.delta.edu/admissions/_documents/authorization-form-dual-enrollment.pdf)</small>