Lebanon Valley College
Office of the Registrar 101 N. College Avenue Annville, PA 17003-1400 (717) 867-6215 Fax (717) 867-6018 www.lvc.edu/registrar
Lebanon Valley College High School Course Registration/Student Information Form Student Name (last, first, middle initial) Home Address
City
Zip Code
Date of Birth
Phone Number (home)
Phone Number (cell)
Anticipated High School Completion Year Email Address (Note: an LVC email address will be created for you and will be used for all LVC communication.)
Citizenship Status: □ U.S. Citizen □ Permanent Resident (Non-U.S. Citizen) □ Neither Permanent Resident nor U.S. Citizen
Are you Hispanic/Latino? □ yes
□ no
Select one or more of the following races: □ American Indian/Alaska Native □ Asian □ Black or African American □ Native Hawaiian or Pacific Islander □ White
Country of Citizenship (if not U.S.):
_________________________________
Requested Courses (Enter your first, second, and third choice) 1._________________ Course Number
_____________
2._________________ Course Number
_____________
3._________________ Course Number
_____________
_____________________________________________________
Section
Course Title
_____________________________________________________
Section
Course Title
_____________________________________________________
Section
Course Title
School District/Private School/Home-School Organization District/Organization Name of District Official/Representative
Position
Contact Day-Time Phone
Email
Course Payment will be made by: _____ District
_____ Student/Parent
I recommend that _________________________________________ be permitted to take the course listed above at Lebanon Valley College. __________________________________________________ Signature of District Official/Representative
____________________________ Date
Page 1 of 2
Student/Parent Affidavit (to be signed by both the student and parent/guardian) I understand this agreement entitles my/me child to enroll in college courses and I agree to the following: 1. 2. 3. 4. 5.
The course is a college-level course and I will meet the same course requirements as college students. I must maintain a minimum 2.5 GPA in all coursework. The grade I receive in this course will appear on my college transcripts. If I withdraw from the course after the drop/add date I will receive a W on my college transcripts. The application entitles me to enroll as a high school student for purposes of dual/concurrent enrollment and does not admit me into the college or a degree program. 6. I am responsible for payment if not sponsored by my home school district. 7. I authorize the college to release my course grade/transcript to my school district at the end of the course. 8. I understand that I must complete an authorization to Release/Withhold information to grant parents, guardians, or others access to my LVC student records.
In signing this form, I agree to the criteria as stated above.
____________________________________________________
______________________
Signature of Student
Date
____________________________________________________
______________________
Signature of Parent/Guardian
Date (10/17)
Page 2 of 2
Lebanon Valley College High School Course Registration/Student Information Form Student Name (last, first, middle initial) Home Address
City
Zip Code
Date of Birth
Phone Number (home)
Phone Number (cell)
Anticipated High School Completion Year Email Address (Note: an LVC email address will be created for you and will be used for all LVC communication.)
Citizenship Status: □ U.S. Citizen □ Permanent Resident (Non-U.S. Citizen) □ Neither Permanent Resident nor U.S. Citizen
Are you Hispanic/Latino? □ yes
□ no
Select one or more of the following races: □ American Indian/Alaska Native □ Asian □ Black or African American □ Native Hawaiian or Pacific Islander □ White
Country of Citizenship (if not U.S.):
_________________________________
Requested Courses (Enter your first, second, and third choice) 1._________________ Course Number
_____________
2._________________ Course Number
_____________
3._________________ Course Number
_____________
_____________________________________________________
Section
Course Title
_____________________________________________________
Section
Course Title
_____________________________________________________
Section
Course Title
School District/Private School/Home-School Organization District/Organization Name of District Official/Representative
Position
Contact Day-Time Phone
Course Payment will be made by: _____ District
_____ Student/Parent
I recommend that _________________________________________ be permitted to take the course listed above at Lebanon Valley College. __________________________________________________ Signature of District Official/Representative
____________________________ Date
Page 1 of 2
Student/Parent Affidavit (to be signed by both the student and parent/guardian) I understand this agreement entitles my/me child to enroll in college courses and I agree to the following: 1. 2. 3. 4. 5.
The course is a college-level course and I will meet the same course requirements as college students. I must maintain a minimum 2.5 GPA in all coursework. The grade I receive in this course will appear on my college transcripts. If I withdraw from the course after the drop/add date I will receive a W on my college transcripts. The application entitles me to enroll as a high school student for purposes of dual/concurrent enrollment and does not admit me into the college or a degree program. 6. I am responsible for payment if not sponsored by my home school district. 7. I authorize the college to release my course grade/transcript to my school district at the end of the course. 8. I understand that I must complete an authorization to Release/Withhold information to grant parents, guardians, or others access to my LVC student records.
In signing this form, I agree to the criteria as stated above.
____________________________________________________
______________________
Signature of Student
Date
____________________________________________________
______________________
Signature of Parent/Guardian
Date (10/17)
Page 2 of 2
