Student Application for Dual Enrollment

Student Information

Legal Last Name

Legal First Name

Middle Name

Preferred First Name

Email Address

Gender

Birthdate

Permanent Home Address

Country

Street

City

Region

Postal Code

Citizenship

School Name

Date of Graduation

High School Advisor

Advisor Phone Number

Family Information

Parent or Guardian #1 Full Name

Phone Number (Personal)

Phone Number (Work)

Employer

Position/Title

Parent or Guardian #2 Full Name

Phone Number (Personal)

Phone Number (Work)

Employer

Position/Title

Intended Course Registration (include term, title, course, and section)

Have you ever incurred disciplinary action or have you ever been suspended, placed on probation, dismissed, or separated from school?

Yes

No

Have you ever been convicted for any violation?

Yes

No

Please attach a separate letter of explanation. Your advisor must also include a statement about your situation with the School Report.

Your signature on this application authorizes the College to inquire about any matters referenced above, and authorizes those contacted to release information.
If you answers to the above questions change to "yes" following submission of the application, you must notify the College immediately.

Kalamazoo College is committed to equal rights, equal opportunities, and equal protection under the law. The College administers its programs without regard to race, creed, religion, age, sex national origin, height, weight, marital status, physical disability as protected by law, or sexual orientation. The College's definition of sexual orientation proscribes discrimination based on a person's heterosexuality, homosexuality, bisexuality, or gender identity, actual or presumed.

High School Counselor Name

Counselor Email

High School Name

High School CEEB Code

Your name below counts as a signature and indicates that all information contained in this application is complete, factually correct, and honestly presented.