DUAL ENROLLMENT ADMISSIONS APPLICATION. You can get anywhere from here.

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1 DUAL ENROLLMENT ADMISSIONS APPLICATION SM You can get anywhere from here.

2 Please print or type: DUAL ENROLLMENT APPLICATION Last Name First Name Maiden/Middle Social Security # Local Address (include apt. #) City State Zip Code Permanent Address (include apt. #) City State Zip Code Phone Number(s) Address Parent/Guardian Address 1. ADMISSION STATUS Please check one of the following options and answer any related questions. o New Student: I have never attended college. Current High School: Current High School Grade: o Former MTC Student: I have taken course(s) at MTC before. If so, the last date I attended was: I was suspended from MTC: o No o Yes 2. BIRTHDATE / / 3. SEX o Female o Male 4. ETHNICITY o Hispanic Latino o Non Hispanic / Non-Latino 5. RACE o Asian o Black / African American o White 6. ENROLLMENT PLAN Semester 7. CITIZENSHIP STATUS o American Indian / Alaskan Native I am an United States citizen: o Yes If no, what country? Year o No If no, my status in the United States is: o Permanent Resident o Refugee / Asylee / Parolee o Visa (Specify) o Other If you are not a U.S. citizen, please submit a copy of your U.S. Citizenship and Immigration Services documentation with this application or within two weeks by: in person; or mail: Midlands Technical College, Admissions Office, ATTN: International Coordinator, P.O. Box 2408, Columbia, SC RESIDENCY INFORMATION I have (or the person who claims me as a tax dependent has) lived in the state of South Carolina continuously for the last 12 months. o Yes o No (See South Carolina residency guidelines at StudentServices/Residency/Residency.htm) If no, I resided in the following state(s): I have (or the person who claims me as a tax dependent has) lived in Richland, Lexington or Fairfield county continuously for the last 12 months. o Yes o No My county of legal residence is: 9. CAREER GOAL Anticipated College Major: 10. ARE YOU CONSIDERING TRANSFER TO ANOTHER SCHOOL LATER? o Two-year college o Four-year college or university o Other type of institution o Not planning to transfer o Undecided about transfer Name of institution being considered City / State * Voluntary information used to comply with federal reporting/career planning reporting that has no effect on admission to the college 11. EMERGENCY CONTACT Name / Relationship Phone Number midlandstech.edu i i

3 DUAL ENROLLMENT AGREEMENT FORM PARENT PERMISSION AGREEMENT Grade Level (during enrolled term): o Freshman* o Sophomore* o Junior o Senior *Students must submit the High School Request Form Anticipated Graduation Year: New or Returning Dual Enrolled Student? o New o Returning It is understood the student must place into the courses he or she wishes to take. Click here o Placement Test : Principal or Designee (printed): Signature and : High School Comments: PARENT PERMISSION AGREEMENT I understand that by allowing my child to participate in the program, I will be responsible for following the guidelines and academic calendar of not only the high school, but also of the college. I hereby give my permission for my son/daughter,., to take Dual Enrolled courses provided by I will be responsible for any tuition and fees associated with courses taken on Campuses. Parent or Legal Guardian STUDENT AGREEMENT To be successful I must attend class, maintain communication with instructors and the high school guidance counselor. I understand that the amount of work necessary to succeed in these courses may be much greater than in high school courses. In addition, Dual Enrolled courses become a part of my permanent college transcript. It is important to do well in these courses to realize all the benefits of the program. Dual Enrolled students are treated the same as any other college student and are subject to all college policies governing students while attending classes offered by MTC. I understand that by becoming a Dual Enrolled student I must abide by the high school s and the college s rules and regulations. As a dependent of my parent, I give MTC permission to release any information regarding my grades, attendance, academic standing, disciplinary action, financial obligations, or any other aspect of my student life to my parents or legal guardians. I also understand that grades, attendance, and any other academic information will be provided to the high school as part of this agreement. I certify that the answers on this applicaton are true, correct, and complete. I further certify that I will notify the Admissions Office immediately if I change my state of legal residence or if my residency status otherwise changes. I attest that I am a US citizen, a legal permanent resident in the United States, or an alien lawfully present in the US. I will submit documentation to support this claim upon request. The South Carolina Illegal Immigration Reform Act (SC Code Ann (Westlaw 2008)) prohibits those unlawfully present in the United States from attending a public institution of higher education in South Carolina and from receiving a public higher education benefit. I understand that submitting false or incorrect information may make me subject to dismissal from the college. Any student who is to be unlawfully present in the US will be dismissed from the college. In the event that I incur a debt as a result of my attendance at the college, I understand any costs associated with collections will be charged to me as the debtor. Student

4 DUAL ENROLLMENT VERIFICATION OF LAWFUL PRESENCE FORM DUAL ENROLLMENT VERIFICATION OF LAWFUL PRESENCE Please use blue or black ink, no pencil. Student s Name Social Security # Career Center / High School Program / Major Received All students must be prepared to provide at least ONE of the following Documentation Types or Combinations as evidence of US Legal Presence. Valid Learner s Permit Valid SC State ID Valid US Passport Valid Permanent Residency Card Valid Federally Issued Visa and a Current School-Issued ID (verified through SAVE) Valid Birth Certificate Accompanied by a Current School-Issued Picture ID Copy Documentation Copy Documentation Below: Signature

5 LOTTERY TUITION ASSISTANCE WAIVER REQUEST Last Name First Name MI MTC ID Address City State Zip Code Phone Number I request a waiver to the Lottery Tuition Assistance eligibility requirement relating to the submission of the Free Application for Federal Student Aid (FAFSA) for the following reason (check all that apply): o I am a high school student enrolled in a dual enrollment program. o I have already earned a Bachelor s Degree and have provided an official transcript to the MTC Admissions Office. o I am enrolled in a program that is not eligible for Title IV federal aid. o I am a dependent student who cannot get my parents signature or Tax Return Transcript. (You must attach a letter from your parents confirming this statement) o I am an independent student who cannot get my spouse s Tax Return Transcript. o I am an independent student and my adjusted gross income is at least $80,000. I will provide a copy of my Federal Tax Return Transcript. o I am a dependent student and my parent s adjusted gross income is at least $80,000. I will provide a copy of their Federal Tax Return Transcript. BY NOT SUBMITTING THE FAFSA, I ACKNOWLEDGE THAT: I will not be eligible to receive other Title IV aid, which includes the Pell Grant, Federal Supplemental Educational Opportunity Grant, Perkins Loan, Stafford Loans, Federal Work Study and the SC Need-Based Grant. Also, I will not be able to participate in state assistance programs that require the submission of the FAFSA. Further, I understand that neither the state of South Carolina nor the institution can be held liable for any amount of federal or state funds that I forgo by signing this waiver. I do not owe a refund or repayment of a state grant, Pell Grant, or Supplemental Educational Opportunity Grant, and I am not in default on a loan under the Federal Perkins Loan, Federal Stafford Loan, William D. Ford Federal Loan, or any state loans. I understand that the institution will verify this. Male Students Only: I have registered with the Selective Service or I have been exempted from this requirement according to federal law. I understand that students who fail to register with the Selective Service or fail to be exempt from that requirement are not eligible to receive Lottery Tuition Assistance. The provided information is correct and if any of the information is false, I understand participation in the Lottery Tuition Assistance Program will be canceled and reimbursement of Lottery Tuition Assistance funds will be required. Further, I understand that if I have attempted to obtain, or have obtained Lottery Tuition Assistance through means of a willfully false statement or failure to reveal any material fact, condition, or circumstance affecting eligibility, I can be subject to the college/university s code of student conduct and applicable civil or criminal penalties. This waiver is not valid until all requested documentation is provided to the financial aid office, and all documentation has been verified. Student Signature Financial Aid Signature o Approved o Not Approved SD

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