MARICOPA Dual Enrollment Office Use Only

COMMUNITY COLLEGES Registration Forn1 Term: ____

Date: ____

□ □ □ □
Check the box in front of the college to identify where you plan to receive crerlit.
Initials: ___
□ □
chandler-Gilbert Estrella Moun lain 0GateWay Glendale Mesa
0Paradis·e Valley Phoenix 0Rio Salado D Scottsdale south Mountain

·PLEASE'PRINlf'J
Legal Name:---------------------------------- Date of Birth (MMIDDIYYYvJ: ______
Last F,rst Midcl!o HS Grade Level: 90 100 11 0 120

College ID II (Required) .1... Email:

To locate your student col 1ege ID number, log in to your Student Center at my.maricopa.edu with your (MEIO) and password. scro!I down lo the Personal lnformafon section, and click ·oemograph!c Oa1a ...
Your student college ID number w.11 be Iha first item listed at the top of lhe page.

Mailing Address/Apt. #/City/Slate/Zip Code: _______________________________ ______

High School Name: ____________________________ Expected High School Graduation Date: _____

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Tenn Year Course Prefix Class Number Class Hour Instructor Credits
(e>amp!e: Fa'I, Sp,ing) (example: 20 I 2) (exarnp'e: ENG IOI) (e>a1np!e: 1234S) (eY.amp:e: !st hour) (exampl�: 3)

Total Semester Credits -- x Credit Hour Rate $ __ = $ __ + $15 Registration Fee TOTAL AMOUNT DUE $ _
In-state Lull Ion• Is $86 per credit hour, plus a $15 registration rec. In some cases, your high school or other party may subsidize the rate per credit hour.
*To qualify for In-state tuition students must provide proof of lawful presence in the United States. According to Arizona law, students who are not citizens or legal
residents, or who do not submit residency documents, will be charged out-of-state tuition. For more Information go to marlcopa.edu/resldency.

STUDENT - PLEASE READ AND SIGN HERE:

I ogree to the exchange of ocodemic illformmion be/1Vee111he µortlclpo1i11g institutions.
inclurli11g bul 11ot limited to college gracle reports, tromuipts. one/ ony 01her 11er//nen1
dowme11rs. I give permission 10 release Maricopa Community Colleges student
information to my poreI11s ondlor legal guordi1111 in occordo11ce with Fer/em/ Im•,.

Student Signature Cell Phone Number Date

(II no Cell Phone put Hume Phone)

PARENT/GUARDIAN - PLEASE READ AND SIGN HERE:
As a pare Ill or /ego/ guordion. I give permission for the obove ,wmecl swdent 10 enroll
in 1he course(s) listed obove. I agree to notify the Dual Enrollment Office at the
college of choice regcmllng changes /11 e11rollme11t, /11clurllng clropp/11g, at/cling,
or clw11glng classes. Failure to poy w/11 result In the above-1wme,I st11Cle11t be/11g
011tomotlcolly tlroppecl from c/ass(es) wltho11t notlf/cotlon. I u11derstond thol lhe
above 11omed st11de111 will /Je es10/Jlislli11g o college arndem/c record 011d will be required
to reporl such e11rollmen1 10 future colleges or 1111iversities. Ne/she will be S11bject to 1he
course requiremenls, gmding s1r111dords wul ottendonce requirements estoh/ished hy the
instwctur ill the course syllobus. I further understond thot the o/Jove-11amecl student l'lill
be subject to oil of lhe requirements. policies, reg11!11tiom, on// de(l{l/ines clefinecl ill //1e
College CCllolog om/ Scl,eclule of Closs es.

Parent/Guardian Printed Name Parent/Guardian Signature Parent/Guardian Email Cell Phone Number Date
(If no Coll Phono pul Home Phone)

THIS BOX TO BE FILLED IN BY HIGH SCHOOL OR COLLEGE OFFICIAL

SAIS#: (Student Accountability Information System) (Required) Accuplacer Score:

□ ACT�22 □ ELA □ MATH

Check all that apply: Write Placer
OPSAT�93 0 SAT�930 D AzMERIT�Proficient Elem. Algebra
College Algebra ---
HB2008 ID Prerequisite Maricopa Grant Reading
I have reviewed the infor·mation on this form, and certify that the student is eligible to participate In dual enrollment.

□ High School
Official
□ MCCCD
Official
AP Score:
ENG
Signature of Official Date Cale NB
A R.S 15·901 requ·res students to be currently enrolled al the school for a full-time fnstwcUonal program in addition to ll1e coUega course. Cale B/C
REV 06/ 14/17 �OTE: High Sc.?1001 Sonlors who satisfy hi{Jh school g1adunfon req uirements are exempl.
Maricopa County Community College District (MCCCD) is an EEO/AA institution and an equal opportunity employer of protected veterans and individuals with disabilities. All qualified applicants will receive consideration for employment without regard to
race, color, religion, sex, sexual orientation, gender identity, or national origin. A lack of English language skills will not be a barrier to admission and participation in the career and technical education programs of the college.The Maricopa Community
Colleges do not discriminate on the basis of race, color, national origin, sex, disability or age in its programs or activities. For Title IX/504 Concerns, call the following number to reach the appointed coordinator: (480) 731-8499. For additional information,
as well as a listing of all coordinators within the Maricopa College system, visit the following weblink: