Lesson Cover Sheet Please staple this sheet to your lesson.

2010-2011 Lesson Cover Sheet Please staple this sheet to your lesson. Find information online: E-mail: K-12 lessons: submit.ttuisd@ttu.edu General inquiries: distlearn@ttu.edu LESSON # GRADE Instructor s Signature If your bar code label has the correct address, attach it below. If your address has changed do not use the bar code label. Write your name and the correct address in the space below and submit a Change Notification Form to our office. Place bar code label here Instructor s Name Course Title INSTRUCTOR, initial if applicable. Student MAY resubmit this lesson for regrading. Student MUST resubmit this lesson for a grade. Original Submission Resubmission will process resubmitted lessons only if the instructor indicates above that the student may or must do so. STUDENT COMMENTS INSTRUCTOR COMMENTS You must pass the final exam to pass the course. 100324

2010-2011 Exam Application Apply for your exam online at: www.courseportal.uc.ttu.edu (you will need to log in) For information on taking your exam, including guidelines for identifying an approved proctor, visit. Student s Name Last First MI I am enrolled as a full-time student in s diploma program. Address City State Zip E-mail Social Security # or matriculation #* Course Name *If you did not provide a valid Social Security # on your enrollment form, you were assigned a matriculation number. Final _ Affix the EX bar label here. Do NOT use bar codes from other courses. Instructor s Name Proctor s Name Title Institution E-mail Institution Address City State Zip Phone ( ) Ext. Preferred Exam Date 100324

2010-2011 Extension Request Request an Extension online: www.depts.ttu.edu/uc/forms/ extension/ For information about extensions, please visit. Date Student s Name_ Social Security # or matriculation #* *If you did not provide a valid Social Security # on your enrollment form, you were assigned a matriculation number. Street Address City State Zip Code Student s E-mail This is a new address. Phone ( ) Ext. Affix the XT bar code label here. I wish to extend: Method of Payment: Enclosed is a check or money order payable to Texas Tech University for $. (K-12 courses $50; dual-credit courses $100) Please charge my credit card (check one): MasterCard Discover Visa American Express Card Number Exp. Date Cardholder Name Cardholder Signature 100324

2010-2011 Change Notification For Name or Address Submit information online: www.depts.ttu.edu/uc/forms/ notification/ You are responsible for notifying the office if your name or address changes while you are enrolled in a course. Do not use your old bar code labels or your lessons will be returned to your old address. New labels will be mailed to you after your change of address is processed. If you need to send in a lesson before your new labels arrive, write your new address in the bar code label box on the lesson cover sheet. Old Information Bar Code # _ Social Security # or Matriculation #* *If you did not provide a valid Social Security # on your enrollment form, you were assigned a matriculation number. Name New Information Bar Code # _ Social Security # or Matriculation #* *If you did not provide a valid Social Security # on your enrollment form, you were assigned a matriculation number. Name Address City State Zip Code Phone ( ) Ext. E-mail 100405

2010-2011 Withdrawal Refund Request Submit a withdrawal refund request online: www.depts.ttu.edu/uc/ forms/withdrawal For information on our withdrawal refund requests, please visit. All requests for withdrawal/refund must be in writing. Refunds will be determined based upon the postmark of the request. Student Name Social Security # or matriculation # *If you did not provide a valid Social Security # on your enrollment form, you were assigned a matriculation number. Address to which refund should be mailed City State Zip Code E-mail Please list all courses to which this withdrawal request applies, along with any books being returned: (Please print legibly.) For Office Use Only If more room is needed, please use back of form or a separate piece of paper. Please indicate the reason for withdrawal/refund: 100324

2010-2011 Course Exchange Request Find information online: All requests for course exchanges must be in writing. Course exchanges will be determined based upon the postmark of the request. A course can be exchanged only once. Once an exchange has occured, no refunds will be made. Student Name _ Social Security # or matriculation # *If you did not provide a valid Social Security # on your enrollment form, you were assigned a matriculation number. Address to which refund should be mailed City State Zip Code I am a full-time student in s diploma program. Please list the course(s) which you would like to exchange and/or any books being returned. The cost for an exchange is $30 per course. (Please print legibly.) Please list the course(s) in which you would like to enroll, and the books you would like to purchase. (Please print legibly.) For Office Use Only PAYMENT INFORMATION Form of Payment Check No temporary checks accepted (payable to Texas Tech University) Ck. # *Driver s License # *Date of Birth Money Order (payable to Texas Tech University) P.O. # Credit Card: MasterCard VISA Discover American Express Card # Expiration Date Cardholder s Name Signature *required when paying by check 100405

2010-2011 BOOK ORDER FORM HOW TO ENROLL: Please legibly print all information on this form. Enroll online at: STUDENT INFORMATION - Failure to complete this information will result in your enrollment being delayed. Social Security Number If you do not provide a valid SSN, you will be assigned a matriculation number. Name Last Name First Name MI Birthdate (MM/DD/YYYY) (Do not leave blank. This information is required.) Mailing Address (for lessons) Address City County (TX only) State Zip Shipping Address (for UPS delivery of course materials) Address City County (TX only) State Zip Home Phone ( ) Work Phone ( ) E-mail Address Grade Level (required to submit lessons via e-mail or to take an online course) PAYMENT INFORMATION Form of Payment Check No temporary checks accepted (payable to Texas Tech University) Ck. # *Driver s License # *Date of Birth Money Order (payable to Texas Tech University) P.O. # Credit Card: MasterCard VISA Discover American Express Card # Cardholder s Name Expiration Date Signature *required when paying by check BOOKS AND/OR MATERIALS ORDER INFORMATION Current textbook information can be found online at or by calling the Bookstore at 800.692.6877, ext. 252. Send me all the books and materials listed for [course name(s) and number(s)] OR Send me the following books and materials: Title New or Used? Cost Overnight shipping will only reduce mail time and does not impact the order in which enrollments are processed. All orders are subject to a 24-hour processing period. Orders received on weekends, University holidays, or after 2 p.m. on Fridays will not be processed until the following business day. Regardless of the shipping method selected (overnight, UPS 2nd-day Air, etc.), ODE must have adequate lead time to fill orders. TEXTBOOK SHIPPING CHARGES Total Books/Materials Cost Textbook Shipping Charge Add amount from chart below. Total Textbook Cost If Total Cost of Textbooks is Add for UPS Ground Add for 2nd Day Delivery Add for Overnight Delivery Up to $39.99 $9.00 $14.00 $29.00 $40-$109.99 $13.00 $20.00 $42.00 Over $110 $15.00 Call Bookstore for pricing Call Bookstore for pricing International Students: If you live outside the contiguous USA, your textbook shipping charge will need to be determined by our Bookstore Manager. Call 1. or, ext. 242, to find out the correct amount before you submit this form. The University reserves the right to make changes at any time without notice. This form is valid from August 1, 2009 to July 31, 2010. Visit our website at or call 800.692.6877 for updated information. This form may be duplicated. 100405

2010-2011 TESTING SERVICES ENROLLMENT FORM For School Districts or Educational Service Centers Ordering Credit by Exams in Quantity Find information online: INSTRUCTIONS E-mail to: testing.ttuisd@ ttu.edu This form has been created for use by school districts and educational service centers when ordering CBEs in quantity. All exams ordered on this form will be sent to the address listed below. Please see that get review material in time to study for their exams. Use this form to indicate the total number of exams you need for each subject area and total costs. Use the Student/Exam Form to list, their Social Security numbers, and the exams they will take. If you are ordering for multiple campuses and would like for the tests to be bundled together by campus, please use a separate Student/Exam Form for each campus and complete the information at the top of each one. If you wish to give an exam to a student other than those listed, you must inform the office. Failure to do so could result in delay of receipt of scores. Any test(s) not taken must be returned with the completed exams. No refunds will be granted for CBEs. Test Date School District or ESC Official s Signature (30 days required for delivery of bulk orders, so plan ahead!) MAILING INFORMATION Information must be completed by school district official; please print legibly. School District Official s Name Title Educational Service Center or School District Name Street Address City State Zip Telephone ( ) County E-mail COST INFORMATION For school districts ordering in quantity, the following discounts apply. Check the appropriate discount: 1-10 exams 11-20 exams 21 or more $40 each $24 each + shipping $17 each + shipping PAYMENT INFORMATION Check No temporary checks accepted (payable to Texas Tech University) Ck. # *Driver s License # *Date of Birth Money Order (payable to Texas Tech University) P.O. # Credit Card: MasterCard VISA Discover American Express Card # Expiration Date Cardholder s Name Signature *required when paying by check THIS FORM MAY BE DUPLICATED 100405

2010-2011 TESTING SERVICES STUDENT INFORMATION FORM For School Districts or Educational Service Centers Ordering Credit by Exams in Quantity Find information online: E-mail to: testing.ttuisd@ ttu.edu Student Name Social Security Number Exams to be Taken THIS FORM MAY BE DUPLICATED 100405

2010-2011 TESTING SERVICES SUMMARY FORM For School Districts or Educational Service Centers Ordering Credit by Exams in Quantity Find information online: E-mail to: testing.ttuisd@ ttu.edu If you are an Educational Service Center ordering for multiple school districts, use one form per district. If you are a school district ordering for multiple campuses, use one form per campus. If you don t need your exams sorted by districts or campuses, you may use only one form. Educational Service Center School District County District Number Campus (if applicable) Name: Name: Name: Name of Credit by Examination Number Needed Cost Ex: ENG 9A 50 $700 TOTAL FOR EXAMS $ SHIPPING $ GRAND TOTAL $ THIS FORM MAY BE DUPLICATED 100405

2010-2011 K-12 PRE-ADMISSION FORM Full-time Diploma Program HOW TO APPLY Find information online: 605 Indiana Avenue STUDENT INFORMATION - Failure to complete this information will result in your application review being delayed. Social Security Number If you do not provide a valid SSN, you will be assigned a matriculation number. Birthdate (Do not leave blank. This information is required.) Grade E-mail Address (required if submitting lessons via e-mail) By providing your e-mail address, you are authorizing to send you relevant information and/or updates electronically. For more information about TTU's Privacy Policy, visit www.ttu.edu/policy/privacy.php. Full Legal Name Last Name First Name Middle Name What name do you go by? Address City State Zip Parents' or Guardians' Name(s) Home Phone ( ) Work Phone ( ) ext. Cell Phone ( ) OPTIONAL INFORMATION Sex Race/Ethnicity (Please check one): White African American Hispanic Asian/Pacific Islander American Indian/Alaska Native Other: Information regarding race/ethnicity is voluntary and will be used in a nondiscriminatory manner, consistent with applicable civil rights laws. Information supplied will be used for Federal and/ or State law reporting purposes. Where did you hear about our program? Circle the best answer, please. Academic Advisor Internet Catalog Conference Friend/Family Member Other (please specify) SCHOOL INFORMATION Last School Attended School Address City County State Zip School Phone ( ) Registrar's Name Registrar's Fax ( ) Reason for withdrawal from previous school: Why do you wish to complete your education through courses from? PAYMENT INFORMATION Form of Payment Check No temporary checks accepted (payable to Texas Tech University) Amount of Check $ Ck. # *Driver s License # *Date of Birth Money Order (payable to Texas Tech University) P.O. # Credit Card: MasterCard VISA Discover American Express Card # Cardholder s Name Expiration Date Signature *Required when paying by check 100405

STUDENT AGREEMENT AS A STUDENT APPLYING FOR ADMISSION TO, I UNDERSTAND THAT: TAKS/TAAS: I should take the TAKS/TAAS test in the appropriate grade level and I must pass the exit level TAKS/TAAS for graduation. I understand that I must arrange for TAKS/TAAS testing (call ). STUDENTS WITH DISABILITIES: s curriculum is developed to meet the standards of the State of Texas and the Texas Education Agency. Written for the average and above-average student, this material is very reading-and writing-intensive and thus the course content cannot be modified. Please note that distance education presents different challenges from traditional classroom-based instruction. FULL-TIME STUDENT STATUS: In order for to verify that you are enrolled as a full-time student for meeting compulsory attendance laws, for receiving Social Security benefits, for driver s education and license renewal, you must be enrolled in four one-semester courses at all times in grades 6-12 or one semester of the elementary curriculum for grades K-5 which is four one semester courses. In addition to being enrolled in the necessary courses, you must successfully complete eight to ten lessons per month in grades 6-12 and be making satisfactory progress in grades K-5. NCAA: If you are applying for or receiving a collegiate athletic scholarship, it is your responsibility to contact the NCAA regarding the core curriculum requirements. RELEASE OF GRADE INFORMATION: policy and applicable law governing the release of student education records permits to release grades for under 18 years of age to the ' parents or legal guardians without requiring student permission. However, a student 18 years of age or older must grant permission for to release grades to parents or legal guardians. In addition, policy and applicable law permits, without prior consent and regardless of age, to release a student s grades to a requesting school if the student is enrolled in or transferring to the requesting school. TRANSCRIPTS: I also agree that, in order for to send a transcript, I must complete at least four semester courses (not CBEs). LESSON SUBMISSION: I acknowledge that, if I submit lessons assignments via e-mail, I agree to receive the resulting grade via e-mail. GRADUATION: I understand that I must complete the last 2.5 credits full course, excluding CBEs, while enrolled in in order to receive a Texas Tech University High School diploma. I certify that this information is complete and correct to the best of my knowledge. I agree to abide by Texas Tech University's policies, rules and regulations. I authorize to verify the information I have provided. If applicable, I also authorize the University to electronically access my Texas Success Initiative (TSI) information. I have read, understand and agree to the policy governing the release of my student education records. yes no I am 18 or older, and I authorize to release my grade(s) to my parents and/or legal guardians. yes no Student s Signature Date (required for all ) Parent s/guardian s Signature (if student is a minor, both parent/guardian and student must sign) If you checked "yes" above, please include your parents and/or legal guardians full legal name(s). 1. 2. 3. 4. ADMISSION CHECKLIST You must submit the following items before your application can be processed. An admission form A $80 non-refundable first-time evaluation fee Transcripts: A copy can be sent with the initial request. An official transcript can be faxed or mailed to us from the student's school at a later time. Student with disabilities documentation as described in the above agreement. If you have been out of for a complete year or more, a $40 non-refundable re-evaluation fee. Please complete the student information section on the front of this form. Failure to complete this information will result in your application review being delayed. reserves the right to make changes at any time without notice. This form is valid from August 1, 2010 to July 31, 2011. Visit or call 800.692.6877 for updated information. This form may be duplicated.

2010-2011 PHYSICAL EDUCATION EQUIVALENT APPLICATION Find information online: STUDENT INFORMATION Date Student SS# Student Name Address City State Zip The applicant understands the he/she is required to spend five hours per week for 18 weeks or 90 hours in not less than 9 weeks participating in the approved program, after the application is approved. A fee of $99 is required for each one-semester course. What will be the activity? Where and when will the instruction take place? We are applying for one semester, two semesters. Check one or the other. $99 per semester. If you request two semesters, be sure the dates that follow reflect the correct time. Dates of instruction. Beginning month day year. MAY NOT BE RETROAVCTIVE Ending month day year. Instructor s name Address City State Zip Instructor s Signature Form of payment must be with the application Check Money order Visa Mastercard Discover Am Exp Card # Exp date Signature of card holder FOR USE ONLY Application Approved Denied Date Signature 100301

2010-2011 PHYSICAL EDUCATION EQUIVALENT REQUEST FOR CREDIT Find information online: STUDENT INFORMATION Date Student SS# Student Name Address City State Zip TO BE COMPLETED BY THE STUDENT AND PARENT OF THE STUDENT I certify that participated in For five hours per week or eighteen weeks of 90 hours in not less than nine weeks form (dates) to. Student signature Parent s signature TO BE COMPLETED BY THE INSTRUCTOR I certify that the above statement signed by the student and parent is true. It is my decision that the student Pass Fail the course. Instructor s signature TO BE COMPLETED BY A NOTARY PUBLIC These statements were affirmed and the form signed before me on this date. Notary s signature Seal FOR USE ONLY APPROVED DENIED DATE SIGNATURE 100301

2010-2011 K-12 ENROLLMENT FORM Courses, Credit By Examinations, Dual-credit Courses You do not have to be enrolled in to take individual courses/cbes for credit. HOW TO ENROLL: Please legibly print all information on this form. Online: Call: 605 Indiana Avenue STUDENT INFORMATION - Failure to complete this information will result in your enrollment being delayed. Students with disabilities should read the information on the website or in the catalog before submitting this enrollment form. Documentation must accompany this form. Social Security Number If you do not provide a valid SSN, you will be assigned a matriculation number. E-mail Address (required if submitting lessons via e-mail & for the Portal) By providing your e-mail address, you are authorizing to send you relevant information and/or updates electronically. For more information about TTU's Privacy Policy, visit www.ttu.edu/policy/privacy.php. Name Birthdate (Do not leave blank. This information is required.) Last Name First Name MI (MM/DD/YYYY) Mailing Address (for lessons) Address City State Zip Shipping Address (for UPS delivery of course materials) Address City State Zip Home Phone ( ) Work Phone ( ) ext. Cell Phone ( ) SCHOOL AND CBE PROCTOR INFORMATION - Failure to complete this information will result in your enrollment being delayed. School Name (If homeschooled or in the full-time diploma program, indicate here) School Phone ext. School Address City County (TX only) State Zip Print Official s name and title here Date (Parent/Guardian if homeschooled) SCHOOL CODES: County District Campus Students enrolling in CBEs - PLEASE READ. If you are attending a public or private school and are enrolling in a CBE, the CBE administrator is a school official unless the school official listed above wishes to designate an alternate proctor. Tutors or officials from non-accredited schools cannot proctor CBEs. CBEs for the full-time diploma program and homeschooled will be sent to the approved designated proctor below. Contact our office for a listing of approved proctors. CBE Approved Designated Proctor Information (complete this section only if you are a full-time diploma program student, are homeschooled, or are enrolled in a non-accredited school) Name (please print) Title School/Facility Name Address Phone ext. COURSE AND/OR CBE ORDER INFORMATION* If you enroll in more than one course, please note that ALL courses will expire six months from the date of enrollment. Course or CBE ID and Name I wish to order the (check only one): Course Cost CBE Course - Online Version Course - Print-based Version * PLEASE READ. Course cost includes tuition and all applicable fees. Textbooks and materials are not included. All enrollments are processed in the order they are received. PAYMENT INFORMATION Form of Payment Total Course Cost Total Textbook Cost (from back of application) Grand Total (Total Course Cost + Total Textbook Cost) Check No temporary checks accepted (payable to Texas Tech University) Ck. # *Driver s License # *Date of Birth Money Order (payable to Texas Tech University) P.O. # Credit Card: MasterCard VISA Discover American Express Card # Cardholder s Name Expiration Date Signature *required when paying by check 100405

OPTIONAL INFORMATION Sex Race/Ethnicity (Please check one): White African American Hispanic Asian/Pacific Islander American Indian/Alaska Native Other: Information regarding race/ethnicity is voluntary and will be used in a nondiscriminatory manner, consistent with applicable civil rights laws. Information supplied will be used for Federal and/ or State law reporting purposes. Where did you hear about our program? Circle the best answer, please. Academic Advisor Internet Catalog Conference Friend/Family Member Other (please specify) STUDENT AGREEMENT I agree to abide by all of the policies and procedures governing. (The Policies are available online at, or obtain a printed copy by calling 800.692.6877.) policy and applicable law governing the release of student education records permits to release grades for under 18 years of age to the ' parents or legal guardians without requiring student permission. If the custodial parent does not want to release grades or other educational information to the non-custodial parent, a court or other legal decree that clearly states that the non-custodial parent does not have any educational rights with regard to the child must be provided to. However, a student 18 years of age or older must grant permission for to release grades to parents or legal guardians. In addition, policy and applicable law permits, without prior consent and regardless of age, to release a student s grades to a requesting school if the student is enrolled in or transferring to the requesting school. I certify that this information is complete and correct to the best of my knowledge. I authorize the University to verify the information I have provided. If applicable, I also authorize to electronically access my Texas Success Initiative (TSI) information. I have read, understand and agree to the policy governing the release of my student education records. yes no I am 18 or older, and I authorize to release my grade(s) to my parents and/or legal guardians. yes no Student s Signature Date (required for all ) Parent s/guardian s Signature (if student is a minor, both parent/guardian and student must sign) If you checked "yes" above, please include your parents and/or legal guardians full legal name(s). 1. 2. 3. 4. BOOKS AND/OR MATERIALS ORDER INFORMATION Current textbook information can be found online at. Send me all the books and materials listed for [course name(s) and number(s)] OR Send me the following books and materials: Title New or Used? Cost Total Books/Materials Cost Overnight shipping will only reduce mail time and does not impact the order in which enrollments are processed. All orders are subject to a 24-hour processing period. Orders received on weekends, University holidays, or after 2 p.m. on Fridays will not be processed until the following business day. Regardless of the shipping method selected (overnight, UPS 2nd-day Air, etc.), must have adequate lead time to fill orders. Textbook Shipping Charge Add amount from chart below. Total Textbook Cost TEXTBOOK SHIPPING CHARGES If Total Cost of Textbooks is Add for UPS Ground Add for 2nd Day Delivery Add for Overnight Delivery Up to $39.99 $9.00 $14.00 $29.00 $40-$109.99 $13.00 $20.00 $42.00 Over $110 $15.00 Call the Bookstore for Pricing Call the Bookstore for Pricing International Students: If you live outside the contiguous USA, your textbook shipping charge will need to be determined by our Bookstore Manager. Call 1. to find out the correct amount before you submit this form. reserves the right to make changes at any time without notice. This form is valid from August 1, 2010 to July 31, 2011. Visit or call 800.692.6877 for updated information. This form may be duplicated.