Dual Enrollment (DE) Student Participation Form

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OFFICE of DUAL ENROLLMENT
5983 Macon Cove, Memphis TN 38134
Main: (901) 333-4251
Fax: (901) 333-4380
Web: https://www.southwest.tn.edu/dual-enrollment/
Email: dualenrollment@southwest.tn.edu

Dual Enrollment (DE) Participation Form

Student Name:

First

Last

Date of Birth:

High School:

Highest Grade Completed:

Anticipated Year of Graduation:

Section A: Authorization to Disclose Information

By signing this form, I (the student) do hereby authorize the release of personally identifiable student record information, pertaining to myself, to my high school officials, college personnel at schools I register at as a DE student for the purposes of consortium agreement, and my parents and/or legal guardians. This information may include, but is not limited to, academic, financial aid, and student account records that are otherwise confidential pursuant to the Family Educational Rights and Privacy Act (FERPA, 20 U.S.C. 1232g) and/or the Tennessee Open Records Act (TNORA, T.C.A. 10-7-504).

Section B: Parent/Guardian Acknowledgement

I give permission for my student to enroll in a DE program. I understand and agree to the following conditions:

I understand that by allowing my student to participate in the DE program, my student is responsible for following the guidelines and academic calendar of the high school and college.
A student must maintain a cumulative 2.0 GPA for all college courses certified under the Dual Enrollment Grant (DEG). Students who do not maintain the minimum GPA will no longer be eligible for the DEG and may be withdrawn from the college.
All fees must be paid by the first day of class. All costs associated with enrollment in college courses shall be the responsibility of the high school, student, or their parent or legal guardian. I promise to pay all fees and charges related to the student’s DE if the DEG does not cover all tuition expenses or if the student does not qualify for the grant.
Eligible students may receive DEG funding for up to 1,296 clock hours.

Section C: Consortium Agreement Acknowledgement—Disregard if not enrolling at two colleges simultaneously.

A consortium agreement establishes a limited agreement between Tennessee Education Lottery Scholarship (TELS) eligible schools that enables an eligible high school student enrolled at both schools within the same term/trimester to have their DEG based upon all enrolled hours. It authorizes the Home school to receive the student’s DEG funds on behalf of the Host school.
If the student signs a consortium agreement with another college as their “Home School”, the DEG will be certified by that college.
I understand that if the student drops/withdraws from courses at either school during the term/trimester of a consortium agreement, the student, parent or guardian may be required to repay the financial aid disbursed.
A student must submit the official Host school transcript for consortium credit/clock hours upon the completion of the term/trimester. DEG eligibility for a subsequent term cannot be determined without required transcripts.

Section D: Immunization Health History

The General Assembly of the State of Tennessee mandates that each public or private postsecondary institution in the state provide information concerning measles, mumps, and rubella, varicella, and hepatitis B infections to all students matriculating for the first time. Tennessee law requires that such students complete and sign a waiver form provided by the institution that includes detailed information about these diseases. The required information below includes the risk factors and dangers of these diseases as well as information on the availability and effectiveness of vaccines for persons who are at-risk for these diseases. The information concerning each disease is from the Centers for Disease Control and the American College Health Association.

The law does not require that students receive vaccination for enrollment. Furthermore, the institution is not required by law to provide vaccination and/or reimbursement for the vaccine.

Hepatitis B (HBV) Immunization

Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver failure, and even death. The disease is transmitted by blood and or body fluids and many people will have no symptoms when they develop the disease. The primary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease is completely preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are required for optimal protection. Missed doses may still be sought to complete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases.

DEV: 4/17/2023 disease. The primary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease is completely preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are required for optimal protection. Missed doses may still be sought to complete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases.

Check the appropriate option below.

I hereby certify that I have read this information and I have had the entire series of the Hepatitis B vaccine.

I hereby certify that I have read this information and I have elected not to receive the Hepatitis B vaccine.

I hereby certify that I have read this information and I have elected to receive the Hepatitis B

vaccine and/or I am in the process of receiving the complete three dose series of the Hepatitis B vaccine.

Measles, Mumps, Rubella (MMR) and Varicella Immunizations

Measles causes fever, rash, cough, runny nose, and red, watery eyes. Complications can include ear infection, diarrhea, pneumonia, brain damage, and death.

Mumps causes fever, headache, muscle aches, tiredness, loss of appetite, and swollen salivary glands. Complications can include swelling of the testicles or ovaries, deafness, inflammation of the brain and/or tissue covering the brain and spinal cord (encephalitis/meningitis), and, rarely, death.

Rubella causes fever, sore throat, rash, headache, and red, itchy eyes. If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects.

Varicella (chickenpox) causes blister-like rash, itching, fever, and tiredness. Complications can include severe skin infection, scars, pneumo nia, brain damage, or death.

You can protect against these diseases with safe, effective vaccination

Check the appropriate option below.

I hereby certify that I have read this information and I have had the entire series of the MMR and Varicella vaccines.

I hereby certify that I have read this information and I have elected not to receive the MMR and Varicella vaccines.

I hereby certify that I have read this information and I have elected to receive the MMR and Varicella vaccines

and/or I am in the process of receiving the complete series of MMR and Varicella vaccines.

Section E: Student and Parent/Legal Guardian Acknowledgement

By signing below, I agree to the terms outlined in this DE Participation Form. I certify all the information provided by me on this form is correct and complete.

Student

Print Name of Student:

Parent/Legal Guardian

Print Name of Parent/Legal Guardian:

Phone Number:

Email Address:

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