Tom P. Haney Technical College Dual Enrollment Registration Form

Tom P. Haney Technical College Dual Enrollment Registration Form

Please complete this form to register for a Tom P. Haney Technical College Dual Enrollment program. All required information must be provided for your form to be processed. You will be contacted via the email you entered on this form. All programs can accept 10% of their student enrollment as dual enrolled students.
Student's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Date of Birth*

MonthDayYear
Date
MaleFemale
American Indian or Alaskan NativeAsianBlackNative Hawaiian/Other Pacific IslanderWhite/Casucasian
U.S. CitizenNon-Resident AlienPermanent Resident
No Military Status (Y)Active Duty (A)Eligible Dependent (D)Veteran (Service Dates Unknown) (E)Active Member of the National Guard (N)Active Member of the Reserves (R)Veteran (Service Prior to 9/11/2001) (V)Veteran (Service on or after 9/11/2001) (W)Unknown/No Response (X)
Employed (E)Not in Labor Force, incarcerated or not eligible for employment (N)Employed but with Notice of Termination or in transition out of military service (S)Unemployed, looking and eligible for employment (U)
Does Not Apply (Z)Single parent (S)Single parent and single pregnant woman (B)Single pregnant woman (W)
Does Not Apply (Z)Unemployed, cared for home/family, unpaid (A)Previously supported by public assistance or relative, no longer supported (B)Parent of child within 2 years of no longer receiving TANF (C)Unemployed dependent spouse of a member of the Armed Forces on active duty (D)
Yes, Hispanic or LatinoNo, Not Hispanic or Latino
Student's Personal Email Address*
Please enter a valid email address
Student's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Program/Course Applying for*
Current High School Name*
Current Unweighted GPA*
2.0 is required for dual enrollment
High School Counselor's Name*
Parent/Guardian Full Name

First NameLast Name
Relationship to Student
Parent/Guardian Email Address
Please enter a valid email address
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*
If you're under 18, your parent or guardian information must be used as your emergency contact
Relationship to Student*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone Number (optional)*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
If yes, what diagnosis? If no, answer "N/A"*
YesNo
If yes, what medications? If no, answer "N/A"*
Upload Picture ID*

Cancelof
Permissions

Please read and agree to the following before submitting your application for dual enrollment
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
STUDENT ACKNOWLEDGEMENT: I certify that the information contained in this application is true and correct and understand that misrepresentationor omission of information may be cause for rejection or dismissal.

I accept the conditions of Career DE (Dual Enrollment) at Tom P. Haney Technical College and understand that as a Career DE student, I am considered a dependent student and that Haney is free to release any information on my enrollment to my parents/guardian and/or high school officials including grades, attendance, and official transcripts. Please type your name below to accept.

I confirm that this information provided in this form is accurate.
Signature (Student or Parent/Guardian for minors)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Tom P. Haney Technical College Dual Enrollment Registration Form

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