Dual Enrollment Application Fall 2022/Spring 2023

Round (Nondegree Enroll Form)

Start Term (App)

Academic Level

Academic Program

Admit Type

Student Type

Start Term Person

App Submit Date

Name

Prefix

First Name

Middle Name

Last Name

Suffix

Nickname/Preferred First Name

Other Last Names Used

Contact Information

Email Address

Mobile Phone

Home Phone

Permanent Address

Country

Street

City

Region

Postal Code

Mailing Address

Country

Street

City

Region

Postal Code

Biographical Information

Sex

Birthdate

Primary Citizenship

Secondary Citizenship

Permanent Resident

Yes

No

Social Security Number (Optional)

Hispanic

Yes

No

Parent/Guardian who will sign the Dual Enrollment Consent Form

Relationship Type

First Name

Last Name

Phone Number

Email Address

Academic History

Please enter information for the high school you are currently attending below.

School Name

CEEB Code

Expected High School Graduation Year

Other Required Information

Ceeb hidden

List the Early College Credit courses you will be taking.

If you are taking more than one course, please list the names of your teachers.

Do you qualify for free and/or reduced priced meals at your school?

Yes

No

Signature

Signature

My signature below indicates that all the information contained in this enrollment form is complete and correct. I am aware that any falsification in the completion of this enrollment form, either by error or omission, may result in my being denied enrollment by the University of Bridgeport or may result in disciplinary action. By providing my signature, I grant the University of Bridgeport permission to obtain my official transcript from my high school as well as verify my qualification for free and/or reduced priced meals.

Signature

Signature Date