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A student registering for dual enrollment at Penn State as an undergraduate non-degree student must complete and return this form to the Admissions Office. Enrollment as non-degree does not imply admission to the University. The student must make formal application to be considered for admission as an undergraduate degree student.

Biographic Information

Last Name: ____________________________ First: ________________________ Middle Initial: _________

Gender: Male: ________ Female: ________ Date of Birth: _________________________________

Enrollment request for: Year _________ Semester (check one): Spring ______ Summer ______ Fall _______

Home/Mailing Address:

Street 1: ___________________________________________________________________________________

Street 2: ___________________________________________________________________________________

City/State/Zip: _____________________________________________________________________________

Phone Number : _______________________________ Cellular Number: ______________________________

E-mail ____________________________________________________________________________________

Emergency Contact Information:

Name: ___________________________________________ Phone Number: __________________________

Relationship: _________________________________ E-mail ______________________________________

Educational Background:

High School Name: ___________________________________________ Year of graduation: _____________

Federal law requires that institutions of higher education gather the following information regarding the ethnicity and race of its students and employees. Your individual information will be kept strictly confidential. The law only requires institutions to report aggregate totals for each category. Select the appropriate responses regarding your ethnicity and your race:

  1. Is your ethnicity Hispanic/Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin)? ?Yes, Hispanic/Latino ? No, not Hispanic/Latino
  2. What is your race? (Select one or more)
    ? White ? Black or African American ? Asian ? American Indian or Alaska Native ? Native Hawaiian or Other Pacific Islander

I have completed all sections of this form and I affirm accuracy of the information provided. Should there be any misrepresentation of the facts on this form, I understand this may be cause of refusal or cancellation of my enrollment.

______________________________________________ _______________________

Signature of Student                                                            Date

______________________________________________ _______________________

Signature of Parent                                                              Date