PALM BEACH STATE COLLEGE
DUAL ENROLLMENT AUTHORIZATION FORM
Instructions
This form must be completed every term for which dual enrollment/early admission is intended and
submitted via the student’s WorkDay portal. I understand that it is my responsibility to register for my classes and secure
textbooks once I have received permission from the dual enrollment office. I also understand that I must attend and
participate on the first day of class and I will not be permitted to re-enroll in a course if a professor drops me for non-
participation or non-attendance.
PART 1 – Student Information Fall Spring Summer Year ______
Last Name First Name PBSC Student ID Unweighted GPA
Birth Date (MM/DD/YYYY) Current Grade Level (during the above requested term) HS Grad Date (MM/YY)
PART 2 – Course & Counselor Certification Dual Enrollment Early Admission
This section must be completed by the student’s guidance counselor or Home Education designee. Courses without pre-
requisites (i.e., ENC1101 or AICE/AP Score for LIT1000) will not be processed and co-requisite (i.e., BSC2085L, CHM1045L)
permissions will be added for you.
Public/Charter Private Home Education/PEP
PBSC Course ID (e.g., ENC1101) Number of Credits PBSC Course ID (e.g., ENC1101) Number of Credits
Name of School Telephone
Name of School Counselor/Designee Signature of School Counselor/Designee Date
PART 3 – Student & Parent Certification
Student: By submitting this request, I understand that I will need to invest the time and energy required to be successful in
college courses, (b) all grades, including “D, F, and W” for withdrawal, become a part of my permanent high school and
college records, and (c) dual enrollment students who receive a D, F, or W in a college course are instantly disqualified from
the program.
Parent/Guardian: By signing this request, you are giving the student permission to participate in the dual enrollment/early
admission program, affirm that you have had a conversation with the student about their ability to take and be successful in
college classes (i.e., considered their high school courseload, athletics, extra-curricular activities, and part-time
employment), and understand the implications failing or withdrawing from a course may have on their future educational
aspirations (i.e., college admissions, scholarships, and/or financial aid).
Student Name Student Signature Date
Parent/Legal Guardian Name Parent/Legal Guardian Signature Date
DE Form (08/2023)
