Dual Enrollment Application

Personal Information

Student First Name

Student Last Name

Do you have a preferred name you would like to provide?

Student Preferred Name (Enter ONLY if different from your first name above).

Student Personal Email Address
*Please use a personal email. School accounts may block incoming messages and interfere with Multifactor Authentication.

Student Birthdate

Enter your U.S. Social Security Number (SSN)
If you have been issued a U.S. Social Security Number, please provide it. This is optional and used for matching financial aid and university records.

Sex

Student Phone Number

Would you like to receive text messages from PennWest?

Yes

No

Mailing Address

Country

Street

City

Region

Postal Code

Are you a Pennsylvania state resident?

Yes

No

How many years have you been a permanent full time resident in Pennsylvania? (0-100) If less than 1 year please enter 0.

What is your official state of Permanent Residency, if residing in the United States?

Primary Citizenship

Course Selection

What term do you plan to take classes?

All summer courses are only available online.

Which location/modality do you prefer for your classes?

How many classes would you like to take?

Please provide your class choices in order of preference.

Preferred Class Choice 1

Preferred Class Choice 2

Preferred Class Choice 3

Preferred course not listed? Tell us what you're looking for.

Educational Information

What school do you currently attend? (Start typing your school name and pick from the dropdown.)

CEEB

What year do you expect to graduate from high school?

When you attend college full time, what will be your intended major? (Select One)

High School Personnel Information

PennWest will contact this high school official to verify academic background information

High School Contact Job Title

High School Contact First Name

High School Contact Last Name

High School Contact Email Address

Parent/Guardian Information

PennWest will contact this individual to verify academic, financial, and communication approvals.

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email Address

Would you like to:

Add another parent/guardian

Parent/Guardian Last Name

Parent/Guardian First Name

Parent/Guardian Email Address

Please submit your electronic signature

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