Ruskin HS | Avila University

Today's Date *

Last Name *Student's last name (include former or maiden name as well)

First Name *First name

Middle NameMiddle name

Former/Maiden

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Marital Status *SingleMarriedHead of Household

Student's Home Phone *

Student's Mobile Phone

Student's High School Email Address *

Parent/Guardian's Name *

Street Address *This is your parent/guardian's address

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Parent/Guardian's Home Phone *

Parent/Guardian's Mobile Phone

Parent/Guardian's Email Address *

Student's Gender *FemaleMale

Student's Citizenship (select one) *I am a Legal Permanent Resident (you will be asked to provide a copy of your Permanent Resident card)I am a Nonresident Alien (you will be asked to provide a copy of your Visa card)I am a U.S. Citizen

Student's Birthday *

What is your expected high school graduation year? *20232024OtherSelect one

Cumulative GPA

If you have enrolled at Avila University previously, please provide the year and term of last enrollment

Select the course for which you are enrolling in Fall 2022 *AR 180 Design Theory (3 credit hours)

Please check this box to indicate your understanding of your information privacy *I UnderstandAs an Avila University student, you are covered under the Family Educational Rights and Privacy Act (FERPA). However, due to your dual enrollment, your information (grades and other identifiable information) can be exchanged between Avila and your high school. Avila will not share your private information with another third party. If you wish for your (non-directory) information to be shared with a specific third party, you must contact the Office of the Registrar for a release form.

Please check this box to indicate your understanding of the terms of this registration *I Understand“I confirm that the information provided on this registration form is accurate to the best of my knowledge. I understand that my enrollment is dependent upon eligibility requirements, approval from my high school/district, and payment of all applicable fees. When enrolled as a dual credit student, I understand that I will be expected to abide by all Avila University policies and conduct expectations.”

Please check this box to indicate you understand you will be contacted *I UnderstandA representative from Avila University will contact you via the student phone number you provided on this registration form to collect your Social Security Number (SSN) following your submission of this form. It is not advised for SSNs to be sent via email or text, so providing your SSN over the phone is the most efficient and secure way to provide this very important information to your file.

Signature *

Dual Credit Registration Form for Ruskin High School Students

Fall 2022