Dual Enrollment Application

Who are you?

First Name

Middle Name

Last Name

Birthdate

Legal Sex

Do you wish to disclose additional information regarding your gender identity?

Gender Identity (Optional)

Address

Permanent Address

Country

Street

City

Region

Postal Code

Do you have a different Mailing Address?

Yes

No

Mailing Address (If different than Permanent Address)

Country

Street

City

Region

Postal Code

Personal Contact Information

Preferred Telephone Number

Personal Email Address

Residency & Citizenship Information

Were you born in the United States (US)?

Yes

No

Social Security Number

Citizenship Country (hidden = USA)

Country of Birth (hidden = USA)

Citizenship Country

Country of Birth

Please select your current Citizenship Status with the US.

Documents should not be emailed as this is not a secure method.

As evidence of your citizenship, you will be required to submit documentation as verification of your status type.

Examples of verification may included Department of Homeland Security I-797 Notice of Action indicating current status, Employment Authorization Card (EAD), Alien Registration card, etc.

Visa Type

Do you identify as Hispanic or Latino/a/x?

Which best describes your background?

Do you identify as being of Portuguese background?

Yes

No

Do you identify as being of Cape Verdean background?

Yes

No

Primary Language(s) Spoken (In the home)

Language 1

Language 2

Academic Background

Current High School

Current HS GPA

I am classified as a:

Freshman

Sophomore

Junior

Senior

Anticipated semester for UMass Dartmouth DUAL Enrollment

Intended Graduation Year

Academic Interest: Hidden

Have you previously participated in Dual Enrollment at UMass Dartmouth?

Yes

No

Have you previously participated in Dual Enrollment at another institution?

Yes

No

College/University Name

Start Date

End Date

High School Counselor

High School Counselor First Name

High School Counselor Last Name

High School Counselor Email Address

Student First Name (Read ONLY, will auto populate to confirm student)

Student Last Name (Read ONLY, will auto populate to confirm student)

Student's SASID #

Current GPA

Student has demonstrated a financial need or low income status has been verified through the Virtual Gateway system and could only participate in Dual Enrollment if financial assistance is provided.

Yes

No

Parent/Legal Guardian Information

Parent/guardian confirmation is required if the applicant is under 18 years of age. A confirmation form will be emailed to the parent/legal guardian listed below. The form will serve as permission for the student to participate in the Dual Enrollment program and for the university to release enrollment information (including grades/transcripts) to the high school.

Relationship Type

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Student First Name (Read Only - will auto populate with student's name)

Student Last Name (Read Only - will auto populate with student's name)

Does the student physically reside with you, the parent/legal guardian?

Parent/Legal Guardian Permanent Address

Country

Street

City

Region

Postal Code

Parent/Legal Guardian Preferred Telephone Number

Parent/Legal Guardian Email

All applicants are required to provide an Emergency Information. May we use this parent as your emergency contact? (If not, you will need to provide information for another contact)

Emergency Contact Information

Emergency Contact First Name

Emergency Contact Last Name

Address (if different than applicant)

Country

Street

City

Region

Postal Code

Preferred Telephone Number

Email

Courses and Credits

Rank by order of preference, three (3) courses you wish to take at UMass Dartmouth. Consult with your guidance counselor before choosing your classes. Available courses and schedules may be found online at umassd.edu/courses or umassd.edu/online/courses/
Please note:

First choice selections are not guaranteed.
Most course offerings will be within general education.
Science and Math course availability is limited.

First Preference Course

Departmental Course #
(Example: Psychology 101)

Class # Section
(Example: 10973-01, 14418-7101)

Course Title
(Example: Intro to Psychology)

Second Preference Course

Departmental Course #
(Example: Psychology 101)

Class # Section
(Example: 10973-01, 14418-7101)

Course Title
(Example: Intro to Psychology)

Third Preference Course

Departmental Course #
(Example: Psychology 101)

Class # Section
(Example: 10973-01, 14418-7101)

Course Title
(Example: Intro to Psychology)

Personal Disclosure Information

Personal Disclosure Question #1

Have you ever had disciplinary action taken against you at an educational institution?

Answer "Yes" if you have ever been found responsible for a disciplinary violation at an educational institution that you have attended from the 9th grade (or the international equivalent) forward, whether related to academic misconduct or behavioral misconduct, that resulted in your probation, suspension, removal, dismissal, or expulsion from the institution?

Yes

No

Since you responded "yes" to the question regarding disciplinary action, you are required to provide a statement describing the situation and end result or current status. You may upload a PDF or Word document below. For your privacy and protection, please do not email responses.

Upload PDF or Word document

Personal Disclosure Question #2

Have you ever been convicted of a felony or other crime?

Note: You are not required to answer “yes” to the criminal history question if the criminal adjudication or conviction:

(1) has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential.
(2) was a first conviction for misdemeanor drunkenness, simple assault, speeding, minor traffic violations, or disturbance of the peace.
(3) any conviction of a misdemeanor where the conviction occurred more than five years prior to the date of this application, unless you were sentenced to imprisonment upon conviction of the misdemeanor, or you have been convicted of another criminal offense within the five-year period.

Yes

No

Since you responded "yes" to the question regarding criminal activity, you are required to provide a statement describing the situation and end result or current status. You may upload a PDF or Word document below. For your privacy and protection, please do not email responses.

FERPA Release

I understand that by submitting this application, I am allowing UMass Dartmouth to share my academic information with my high school administrators.

Yes, I understand and agree

Acknowledgment of Additional Billing

The cost of a 3-credit course through Dual Enrollment is $540.00. Grant funding may be available to students who demonstrate financial need to offset tuition and fees for one, 3-credit course per semester. However, all students will be responsible for purchasing any required books, materials, or supplies. The high school will confirm students’ eligibility for grant funding. The student will be notified of their eligibility to receive grant funding at time of registration.

Acceptance of the University’s student Financial Responsibility Agreement (FRA) is required by each student in order to access the portal. The student Financial Responsibility Agreement provides important information to students about the cost of their education and the financial policies associated with their enrollment at UMass Dartmouth. This agreement sets forth the expectations for payment and policies related to, among other things, non-payment, collections, communications, financial aid, and student privacy (FERPA). The agreement also describes UMass Dartmouth’s business processes. Please review here: https://www.umassd.edu/bursar/financial-responsibility-agreement/

Acknowledgement

By checking this box, I confirm I have read the FRA and agree to its terms.

Signature

Click to Sign...

High School Counselor Approval

By my signature, I recommend this student to participate in the Dual Enrollment program at UMass Dartmouth

High School Counselor Signature

Click to Sign...

Parent/Legal Guardian Signature and Acknowledgment of Additional Billing

The cost of a 3-credit course through Dual Enrollment is $540.00. Grant funding may be available to students who demonstrate financial need to offset tuition and fees for one, 3-credit course per semester. However, all students will be responsible for purchasing any required books, materials, or supplies. The high school will confirm students’ eligibility for grant funding. The student will be notified of their eligibility to receive grant funding at time of registration.

Acceptance of the University’s student Financial Responsibility Agreement (FRA) is required by each student in order to access the portal. The student Financial Responsibility Agreement provides important information to students about the cost of their education and the financial policies associated with their enrollment at UMass Dartmouth. This agreement sets forth the expectations for payment and policies related to, among other things, non-payment, collections, communications, financial aid, and student privacy (FERPA). The agreement also describes UMass Dartmouth’s business processes. Please review here: https://www.umassd.edu/bursar/financial-responsibility-agreement/

I acknowledge the additional billing statement above

I am granting permission for my student to participate in the Dual Enrollment program at UMass Dartmouth. I understand that by confirming below, I also allow UMass Dartmouth to release enrollment information (including grades/transcripts) to my student's high school.

Parent/Legal Guardian Signature

Click to Sign...