Dual Credit Registration and Consent Form
Date of Birth
SWIC ID Number
Student Email Address
Preferred Phone Number
Parent or Guardian Phone
Parent or Guardian Email Address
Address (Permanent Residence)
Current Grade Level
High School Name
Belleville East High School
Belleville West High School
Cahokia High School
Career Center of Southern Illinois
Chester High School
Collinsville Area Vocational Center
Collinsville High School
Columbia High School
Dupo Senior High School
East Saint Louis Senior HS
Father Mcgivney Catholic High School
Freeburg High School
Gateway Legacy Christian Academy
Granite City Senior High School
Highland High School
Madison Senior High School
Maryville Christian School
Mascoutah High School
Mt. Olive High School
New Athens High School
O'Fallon Township High School
Red Bud Community High School
Sparta High School
Steeleville High School
Triad High School
Valmeyer High School
Waterloo High School
Enter the course information provided by your instructor below for each class you are enrolling in for the semester selected above.
Student Signature (
Type your full name for electronic signature.
The aforementioned student is a dual credit student and is receiving both college credit and high school credit and will not be responsible for tuition or fees for the classes listed above. Dual credit students are not eligible for college financial aid. Academic coursework while attending Southwestern Illinois College is considered work for college credit; standard college academic policies and procedures will be followed including assessment requirements, prerequisites, student code of conduct and more.
I authorize Southwestern Illinois College under the guidelines of the Family Educational Rights and Privacy Act of 1974 (FERPA) to release or discuss educational records to high school representatives and parents/gaurdians. FERPA is a federal law designed to protect the privacy of education records, to establish the rights of students to inspect and review their educational records, and to provide guidance for the correction of inaccurate and misleading informational and formal hearings.
I have read and agree to the statements above.
Additional Data for Enrollment
Part Time (over 15 hours per week)
Part Time (15 hours or less per week)
Transfer to a four-year college
Improve skills for present job
Future job after community college
Prepare for GED or improve skill
Personal interest or self-development
Transfer Plan - Transfer to a four year college?
Not planning to transfer
I plan to transfer to a four-year college
Disability Classification (optional)
Deaf/Hard of Hearing
Systemic/Chronic Health Problems
Federal Perkins Data
What is your parent status?
Not a Parent (not pregnant)
Single Parent (or pregnant)
Married Parent (or pregnant)
Do your parents have a bachelor's degree?
Neither One Does
Yes, One Does
Yes, Both Do
Is one or both of your parents active duty military?