PALM BEACH STATE COLLEGE

DUAL ENROLLMENT AUTHORIZATION FORM

This form must be completed every term for which dual enrollment is intended.
Instructions
A Palm Beach State College admissions application must be completed if this is the students first time requesting
authorization to dual enroll. This form must be completed and submitted to the Admissions & Registration Office at any
Palm Beach State College campus.

PART 1 – Student Information Fall Spring Summer

2021
Year ______

Dixon Laila L16444283

________________________________________________________________________________________________________
4.0
Last Name First Name PBSC Student ID Unweighted GPA
08/05/2005 10th 05/28/2023
________________________________________________________________________________________________________
Birth Date (MM/DD/YYYY) Current Grade Level Expected HS Graduation Date (MM/DD/YYYY)

PART 2 – Dual Enrollment Course Approval Dual Enrollment Early Admissions

This section must be completed by the student’s HS Dual Enrollment Designee/Home Education official. Please legibly write and
initial each requested course within the chart below. Courses that are illegible, have “white-out” under them or are crossed
out will not be processed.
Public/Charter Home Education Private

PBSC Course ID (e.g. ENC1101) Credit Hours HS Subject Area Met Designee Initials
SPC 1017 3 Performing Art TR
HSC 2100 3 Physical Ed. TR

Santaluces Community High School

________________________________________________________________________________________________________
561-649-6057
Name of School Telephone Number
Tara Robinson 11/06/2020
________________________________________________________________________________________________________
Name of Dual Enrollment Designee Signature of Dual Enrollment Designee Date (MM/DD/YYYY)

PART 3 – Student & Parent Certification

My signature indicates I have thoroughly read and will comply with the requirements and procedures of the Dual Enrollment
program at Palm Beach State College. I also understand that all courses while in the program will be posted to my permanent
college and high school records.

________________________________________________________________________________________________________
Student Name Student Signature Date (MM/DD/YYYY)

________________________________________________________________________________________________________
Parent/Legal Guardian Name Parent/Legal Guardian Signature Date (MM/DD/YYYY)

DE Form (01/2020)