A student registering for the Dual Enrollment at Penn State as an undergraduate non-degree student must complete this form and submit it to the Admissions Office. Enrollment as non-degree does not imply admission to the Pennsylvania State University. The student must make formal application to be considered for admission as an undergraduate degree student after graduating high school.

Biographic Information
Semester:
Home/Mailing Address:
Emergency Contact Information:
Educational Background:
Residency Status and Ethnicity:
Are you a U.S. Citizen?
If no, which of the following statements describes your citizenship status?
Are you a legal resident of the Commonwealth of Pennsylvania?
Is your ethnicity Hispanic/Latino?
Federal law requires that institutions of higher education gather the following information regarding the ethnicity and race of its students and employees. Your individual information will be kept strictly confidential. The law only requires institutions to report aggregate totals for each category. Select the appropriate responses regarding your ethnicity and your race:
What is your race? (Select one or more)
Signatures
I have completed all sections of this form and I affirm accuracy of the information provided. Should there be any misrepresentation of the facts on this form, I understand this may be cause for refusal or cancellation of my enrollment. Sign below.
I have read the terms and conditions of the Dual Enrollment agreement and give permission for my child to enroll in a Penn State Fayette Dual Enrollment course. Sign below.