Kirkwood Community College

Post Secondary Enrollment Option (PSEO) Registration Form

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Last First Middle Initial Social Security Number or Kirkwood K#

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Street Address or P O Box Number City State Zip Code

______Male / Female

Area Code Phone Number Date of Birth Circle One

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Name of High School Anticipated Year of High School Graduation

______

Parent or Guardian Name Street Address City State Zip

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Student’s Email Address (this is required for Kirkwood ATAW Online Course)

Racial / Ethnic / Gender Information:

The following are voluntary questions used for state & local reports. With which of the following groups do you identify?

___ (AI) American Indian /Alaskan Native ___(HI) Hispanic ___(AS) Asian or Pacific Islander

___(AL) Non-Resident Alien ___(NO) Prefer not to answer ___(CA) Caucasian

___(BL) African American/Non-Hispanic ___ (MUL) Multiple ___ (OT) Other

Do you have a disability for which you will need special accommodations? YES ____ NO ____

Will any of the following courses be paid for directly by the student’s family instead of the high school?

If yes, please indicate all courses paid for by the family by marking an X under “paid by student” below. If the course is being paid for by the high school district office, please leave the column blank. Courses paid for by the student will be charged at the regular college tuition rate, and student will be responsible for obtaining their own book from the Kirkwood bookstore, and will pay full cost for the price of the textbook.

Kirkwood course that you wish to register for: Paid by Student?

Course Name______Catalog/Section ______Synonym #______

I hereby authorize Kirkwood Community College to release my Kirkwood confidential student information such as my grades, unofficial transcripts, attendance records and related academic information to my high school pertaining to my enrollment in Kirkwood college credit classes while a high school student.

My parents/guardians and I understand that the Iowa Postsecondary Enrollment Options Act (PSEO) stipulates that when a grade of ‘F’ or ‘W’ has been assigned, my family is responsible for repaying the school district the amount of tuition not to exceed $250 per course. Course grades will become a part of both high school and college records. I also understand that it is my responsibility to return my textbook at the end of my course to my high school guidance office, or I will incur an additional direct charge, for the full cost of the textbook, from the Kirkwood Bookstore. Our signatures indicate understanding of the release of information as well as our knowledge of financial repayment obligations.

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Student Signature Authorization Date (Release Valid for 12 months)

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Parent-Guardian (only required for PSEO courses) Authorization Date (Release Valid for 12 months)

Local School District Approval for PSEO Courses must be received before Kirkwood can process this registration form. Please be sure that this form is signed by student, parent and school official before returning to Kirkwood Community College for registration.

Name of School District ______

Name of High School ______

School Contact Person ______

Title ______Phone ______

School District Verification

I verify that the student identified on this application is eligible for participation in the Postsecondary Enrollment Options Act college classes. Our school district as identified above, agrees to make payment in accordance with provisions of this Act and established Kirkwood Community College policies and guidelines relative to tuition, fees, books, and refunds in the event this student withdraws from courses.

______Date ______

Signature of Authorized School Official

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Kirkwood Community College Disposition

______Approved

______Disapproved ______

Reason for denial

______Date ______

Kirkwood Representative/Official

Completed forms should be submitted to:

Kirkwood Lincoln Center

912 18th Ave SW

Cedar Rapids, IA 52404

Fax: 319-398-1049

If returning this form via fax, please note that both sides must be sent before Kirkwood can register the student.

Revised 12/8/08