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A student registering for dual enrollment at Penn State as an undergraduate non-degree student must complete and return this form to the Admissions Office. Enrollment as non-degree does not imply admission to the University. The student must make formal application to be considered for admission as an undergraduate degree student.

Biographic Information

Last Name: ____________________________ First: ________________________ Middle Initial: _________

Gender: Male: ________ Female: ________ Date of Birth: _________________________________

Enrollment request for: Year _________ Semester (check one): Spring ______ Summer ______ Fall _______

Home/Mailing Address:

Street 1: ___________________________________________________________________________________

Street 2: ___________________________________________________________________________________

City/State/Zip: _____________________________________________________________________________

Phone Number : _______________________________ Cellular Number: ______________________________

E-mail ____________________________________________________________________________________

Emergency Contact Information:

Name: ___________________________________________ Phone Number: __________________________

Relationship: _________________________________ E-mail ______________________________________

Educational Background:

High School Name: ___________________________________________ Year of graduation: _____________

Federal law requires that institutions of higher education gather the following information regarding the ethnicity and race of its students and employees. Your individual information will be kept strictly confidential. The law only requires institutions to report aggregate totals for each category. Select the appropriate responses regarding your ethnicity and your race:

  1. Is your ethnicity Hispanic/Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin)? ?Yes, Hispanic/Latino ? No, not Hispanic/Latino
  2. What is your race? (Select one or more)
    ? White ? Black or African American ? Asian ? American Indian or Alaska Native ? Native Hawaiian or Other Pacific Islander

I have completed all sections of this form and I affirm accuracy of the information provided. Should there be any misrepresentation of the facts on this form, I understand this may be cause of refusal or cancellation of my enrollment.

______________________________________________ _______________________

Signature of Student                                                            Date

______________________________________________ _______________________

Signature of Parent                                                              Date

 

Parental Consent Form

Dual Enrollment—2014/2015 Academic Year Terms and Conditions

Please note the following guidelines for dual enrollment through Penn State Fayette:

  • For consideration, high school seniors must have a minimum cumulative grade-point average of 3.0.
  • For consideration, high school juniors must have a minimum cumulative grade-point average of 3.0 and provide a standardized test score.
  • A guidance counselor approval form is needed.
  • Seniors may take up to 8 credits per semester and earn a maximum of 16 credits. Juniors and underclassman must contact Tricia Homonai to learn about their credit options.
  • Students must earn a grade of “C” or better in each course to remain in the program.
  • Credits earned under the provision of Dual Enrollment are valid at any Penn State location and may be transferred to another institution in the same way as other Penn State credits.
  • Students who have graduated from high school may not participate in this program.
  • Home-schooled students need to contact Tricia Homonai at 724-430-4138 to determine eligibility for enrollment.

Estimated Tuition with 50% Grant-In-Aid (based on 2014-2015 tuition costs)

  • 3 Credits—Tuition $1572.00
    50% Grant-in aid $786.00
    Balance Due** $786.00
    Fees* $143.00
  • 6 Credits—Tuition $3144.00
    50% Grant-in aid $1572.00
    Balance Due** $1572.00
    Fees* $327.00
  • 8 Credits—Tuition $4716.00
    50% Grant-in aid $2358
    Balance Due** $2358.00
    Fees* $435.00

*Additional Costs/Fees—Textbooks and supplies (if required)

**PLEASE NOTE:
These costs are estimates. A final bill will be electronically sent with exact figures. It is the student’s responsibility to arrange tuition payment. A special part of the Dual Enrollment program is a grant-in-aid in the amount of 50 percent of the tuition for a maximum of 8 credits per semester. Books, technology fees, and activity fees will also be applied. Students enrolled in a school that participates in the Dual Enrollment Grant may be eligible for additional funding to offset some or all of the remaining cost. Students are encouraged to ask their high school counselor for more information.

I have read the terms and conditions of the dual enrollment agreement and give permission for my child to enroll in a Penn State Fayette Dual Enrollment course.

________________________________________________ __________________________________

Signature of Student                                                                Date

________________________________________________ __________________________________

Signature of Parent                                                                   Date

 

Guidance Counselor Approval/Transcript Request

I grant permission for_________________________________ to take courses through the Penn State Fayette Commonwealth Program and I verify that:

High school seniors have a minimum cumulative grade point average of 3.0.

High school juniors and underclassman have a minimum cumulative grade point average of 3.0, and a standardized test score.

________________________________________ ______________________
Guidance Counselor Signature                                Date

________________________________________ ______________________
Print Guidance Counselor Name                             Phone

________________________________________
School Name

Guidance Counselors:

Please submit this form and the student’s official high school transcript to the Admissions Office at Penn State Fayette. For Juniors and underclassman, please submit standardized test score and current schedule.

By fax to: 724-430-4175

Or by mail to: Penn State Fayette, The Eberly Campus
Admissions Office/Dual Enrollment
2201 University Dr.
Lemont Furnace, PA 15456