Dual Enrollment Student Application


You are considered a dual-enrolled student if you will be taking college courses while you are in high school (prior to graduating) and your high school participates in our dual enrollment program.

Participating high schools:

  • Elk Lake
  • Liberty
  • Mansfield
  • New Covenant Academy
  • Northeast Bradford
  • North Penn
  • Susquehanna Career and Technical School
  • Wellsboro

If you meet this criteria, please complete the application below.

*Required

Personal Information

*Last Name:     *First Name:     *M.I.:

Social Security Number:
The Federal Privacy Act of 1974 requires that you be notified that disclosure of your Social Security Number is voluntary and is not required to determine admission. Your Social Security Number will be used to match your application with your SAT/ACT Test Scores and/or Financial Aid information so failure to provide it may affect your eligibility for financial aid and may delay decision of admission. Your Social Security number is also used to report your educational expenses to the Internal Revenue Service to verify any education-related deductions you may claim on your federal income taxes.

*Gender:     *Date of Birth: (MM/DD/YY)

Contact Information

Home Phone:     Cell Phone:

*Email address:

*Street Address:

*City:     *State:     *Zip code:     County:

Parent/Guardian Information

*Last Name: *First Name:

*Street Address:

*City:     *State:     *Zip code:     County:

Phone:     Email address:

High School Information

*High School Name:

High School Address:

*Anticipated High School Graduation Date:

Enrollment Information

  

Course Registration

WebAdvisor will allow you to search for available courses

*Enter the Section Name and Title, Meeting Days/Time, Faculty Name, and Credits
(Example: ACC-1110-01 (27146) Prin of Acctg I, Tues & Thur 8:30 - 9:45 am, A. Havalchak, 3.00 credits)

Ethnic/Racial Information

We ask each applicant to provide information about his/her ethnic & racial background. We use this information solely to help us in determining whether the university is being successful in its efforts to assure equal opportunities to all persons. Please select the appropriate ethnic & racial identification below:

What is your ethnicity?

What is your race? Mark one or more races to indicate what you consider yourself to be:




 

 
Send questions/comments to Rachel Green: rgreen@mansfield.edu or call 570-662-4243