Dual Enrollment Parent/Guardian Authorization

Please read this page in its entirety. Your electronic signature at the bottom of this page is required for your student to be admitted to Austin Peay State University's Dual Enrollment program. Please contact our office at 931-221-7175 or e-mail govnow@ngskmc-eis.net if you have any questions.

Immunizations

Each Dual Enrollment student must provide information regarding their immunization record below. The General Assembly of the State of Tennessee mandates that each public or private postsecondary institution in the state provide information to all students entering the institution for the first time.

Please visit the Boyd Heath Services immunization page for more information.

Financial Concerns and Obligations for Dual Enrollment Students

Students must submit complete applications for the Tennessee Dual Enrollment Grant (DEG) by posted deadlines through the TSAC Student Portal: http://www.tn.gov/collegepays/tsac-student-portal.
Students and parents both understand the student must maintain a college GPA of at least 2.00 to continue receiving DEG funding in subsequent dual enrollment semesters.
Students who do not have a 3.0 high school GPA or 21 ACT composite will only receive a grant award for one dual enrollment course per semester.
Students taking courses in the same semester with two different institutions will provide any required documentation in order to participate in the consortium agreement between those institutions, which includes having college transcripts sent at the beginning of each semester.
Textbooks are not covered by 365bet or the TN Dual Enrollment Grant. It is the student's responsibility to utilize the Textbook Express tool located in their OneStop Web Self-Service to determine their textbook needs. When in doubt, reach out to your instructor or our office to confirm your textbook needs.

As parent/guardian of the student named below, my signature on this form certifies that I have read and understood the early admission and concurrent (dual/joint enrollment, academically talented) enrollment policies, including:

Program and course requirements
Students must maintain an 365bet GPA of 2.75 to remain in the dual enrollment program for subsequent semesters while in high school. If their 365bet GPA falls below 2.75 and they have a 3.0 high school GPA, they may reapply for admission.
Financial obligations, lottery grant regulations, discount/waiver eligibility: I understand that I am responsible for the payment of any tuition or fees not covered by the dual enrollment grant. I understand that textbooks are not covered by the dual enrollment grant and will be an out-of-pocket cost if not provided by the student's high school.
Privacy and confidentiality regulations: Dual Enrollment student information is protected by FERPA. Austin Peay State University and the student's high school may exchange information, but information available to parents is limited. Please see our Student Information page here. Submission of a FERPA form is strongly recommended and can be accessed from the student's OneStop Account. Once logged in click on Web Self Service and select the Student Tab.

Please don't fill out this input box.

Your Student's First Name:*

Your Student's Last Name:*

Your Student's Date of Birth:*

Your Student's High School:*

Your Student's Email Address*

Hepatitis B (HBV) - please select the appropriate statement as it refers to your student:*

Date of completion of the Hepatitis B vaccination series (MMDDYY):*If your student has not completed the vaccination series, please type "NA".

Meningococcal Meningitis - please select the appropriate statement as it refers to your student:*

Date of completion of the Meningococcal Meningitis vaccine (MMDDYY):*If your student has not received the vaccine, please type "NA".

ELECTRONIC SIGNATURE ACKNOWLEDGEMENT AND CERTIFICATION OF UNDERSTANDING

I hereby give permission for my son/daughter to enter the Austin Peay Dual Enrollment program, and I understand the conditions regarding eligibility, program requirements and financial obligations.

ELECTRONIC SIGNATURE. This Acknowledgement and Certification of Understanding ("Acknowledgement") is to let you know that by submitting an electronic signature, you are providing an electronic mark, that is held to the same standard as a legally binding equivalent of a handwritten signature provided by you. For purposes of the acknowledgement, a digital mark is considered a typed legal First and Last name (legal name may include middle name, initial or suffix) followed by the typed date. Any document requiring an electronic signature may contain a signature acknowledgment statement provided in the same area requiring the electronic signature.

AGREEMENT: By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

CERTIFICATION OF UNDERSTANDING: I also understand, acknowledge, agree and certify that:

• I accept my responsibilities in the use of electronic signatures as described on this form.

Parent/Guardian E-Signature*Please include your first and last name.

Date and Time of Acknowledgement*

Your phone number:*

Austin Peay State University does not discriminate on the basis of race, color, religion, creed, national origin, sex, sexual orientation, gender identity/expression, disability, age, status as a protected veteran, genetic information, or any other legally protected class with respect to all employment, programs and activities sponsored by 365bet. http://chjo.ngskmc-eis.net/policy. Policy 6:003 AP90/9-17/250