Return this form to any JC location or e-mail to admissions@jccmi.edu.
Complete Sections I and II
1. Meet with your high school counselor to select courses and obtain approval in Section III.
2. Submit a new registration form for each semester that you plan to attend JC as a dual enrolled student.
SECTION I – DEMOGRAPHIC INFORMATION (COMPLETED BY STUDENT)
When do you plan to enroll? year HIGH SCHOOL GRADUATION YEAR ___________________
VALID ONLY FOR THE SEMESTER CHECKED
q Summer (May – August)
q Fall Semester (August – December)
q Spring Semester (January –
April)
NAME (Please use your legal name)
LAST FIRST MIDDLE INITIAL
ADDRESS
NUMBER AND STREET q PO BOX OR q APARTMENT NUMBER
CITY STATE ZIP CODE
MESSAGE PHONE CELL PHONE HOME PHONE
E-MAIL
DATE OF BIRTH*
M M D D Y Y Y Y
EMERGENCY CONTACT TELEPHONE
HOME PHONE NUMBER ALTERNATE PHONE NUMBER q BUSINESS q CELL
EMERGENCY CONTACT NAME _______________________________________________ RELATIONSHIP __________________________
NON U.S. CITIZEN ONLY
ALIEN RESIDENT NUMBER HOME COUNTRY
VISA TYPE: q F1 STUDENT q B VISITOR q H WORKING q OTHER __________________________________________________________________________
ATTACH COPY OF DOCUMENTATION FOR ADMISSION. CONTACT ENROLLMENT SERVICES OFFICE AT 517.796.8425 FOR DETAILS.
REV 06.1.20
DUAL ENROLLMENT AND
HIGH SCHOOL GUEST STUDENT REGISTRATION
JC is FERPA compliant and only releases information to authorized institutions.
Contact the Registrar’s oce for more information and options for non-disclosure.
GENDER
q Male
q Female
Jackson College is committed to providing the best customer service possible while protecting our students’ privacy. Exemplary customer service can include friendly
reminders and messages. By providing a message phone number, I consent to JC leaving messages (voicemail, text messages and/or verbal messages with any person
who answers at this number) with specic information related to JC (course enrollment, appointments, advising, nancial aid, payments, admission, etc.).
EXT.
ETHNICITY (OPTIONAL)
1. Are you Hispanic or Latino? q Yes q No
2. Select one or more as appropriate:
q American Indian or Alaska Native q Asian q Black or African American q Native Hawaiian or other Pacic Islander q White
*Date of Birth is used to fulll federal and state reporting requirements
and is not used to determine admission to Jackson College.
JC OFFICE USE ONLY
______________ Staff Initials
______________ Date
REV
1.22.24
SECTION II – ACKNOWLEDGEMENT (SIGNED BY THE STUDENT & PARENT/GUARDIAN)
As a dual enrollment or high school guest student at Jackson College, I certify that all of the answers on this form are complete
and accurate to the best of my knowledge. I agree to become knowledgeable about Jackson College’s policies and procedures
and abide by them, including policies related to the adding and dropping of courses. I understand that I am creating a permanent
JC academic record. I understand that withdrawal from a course(s) may impact my future ability to receive certain forms of nan-
cial aid and my eligibility to play in college athletics. I authorize JC to send registration information/grades to my high school, when
the school is paying for the course(s). I further acknowledge that I am aware that some college courses contain adult content.
______________________________________________________________________ _______________________
Student’s Signature Date
As parent/guardian, I authorize my dependent to enroll at Jackson College and understand that I am responsible for all tuition and
fees not covered by the school (billing information will be sent to student’s home address if tuition and fees are not covered by
school). I understand enrollment creates a permanent college transcript and I concur with the high school ocial regarding course
selection. I further acknowledge that I am aware that some college courses contain adult content.
______________________________________________________________________ _______________________
Parent/Guardian’s Signature Date
SECTION III – PERMISSION & BILLING AUTHORIZATION (COMPLETED BY SECONDARY SCHOOL)
I certify that ______________________________________ is currently enrolled at ____________________________________
(NAME OF STUDENT) (NAME OF SCHOOL)
AND
• Meets the conditions outlined in the Michigan Postsecondary Enrollment Options Act (www.michigan.gov/mde);
• Has received the prescribed counseling required under the Postsecondary Enrollment Options Act from the sponsoring school;
• Understands that granting of credit toward high school requirements rests entirely with the sponsoring school; and
• Has demonstrated the skills and abilities to successfully complete the college courses recommended.
It is understood that if the secondary school is paying for course(s):
• Jackson College will send a written notice to the school district indicating the course(s) enrollment information
• Jackson College will send a bill to the school district after conclusion of JC’s add/drop period for the course(s)
• Jackson College will send the school district the grades for courses paid for by the school
COURSE INFORMATION MUST BE COMPLETED BY THE HIGH SCHOOL – DO NOT LEAVE SECTION BLANK PLEASE CHECK ONLY ONE BOX IN AREA BELOW
CHECK COURSE LETTERS AND MEETING MEETING JC BOTH HS HS AUDIT
A = ADD SECTION DAYS TIME CREDIT & COLLEGE CREDIT NO CREDIT;
D = DROP (EXAMPLE: SOC 231 01) ONLY CREDIT ONLY NO GRADE
q A q D
q A q D
q A q D
q A q D
______________________________________________________________________ _______________________
School Counselor or Designated School Ocial Signature Date
_____________________________________ q agrees q does not agree to pay for tuition and fees for dual enrolled student.
(NAME OF SCHOOL)
_____________________________________________________________________ _______________________
School Ocial Signature Date
PLEASE COMPLETE SCHOOL BILLING INFORMATION BELOW IF TUITION AND FEES WILL BE COVERED BY THE SCHOOL.
Billing Address: __________________________________________________________________________________
Comments: _____________________________________________________________________________________
