Student Application

completed on Hinds

website

Student Letter of

Recommendation

Student/Parent

Agreement Form

Student/Parent

Payment Form

Student ACT or

ACCUPLACER

scores (on file with

Hinds CC)

Student Transcript

1. GO TO HINDSCC.EDU

2. CLICK ON “APPLY NOW”

3. CLICK ON “CREATE A PROFILE” AND COMPLETE

4. COMPLETE THE “APPLY ONLINE” (BE CAREFUL TO CHOOSE THE CORRECT

SEMESTER YOU WILL BE ATTENDING COLLEGE)

*KEEP UP WITH YOUR HINDS ID NUMBER ONCE IT HAS BEEN ASSIGNED! AND

ALWAYS CHOOSE AN EMAIL ADDRESS AND PASSWORD YOU CAN EASILY

REMEMBER!

;

ANDTHIS WILL BE COMPLETED IN YOUR COUNSELOR’S OFFICE AND DOES REQUIRE

YOUR SIGNATURE.

THIS IS A REQUIRED DOCUMENT THAT BOTH THE STUDENT AND THE PARENT

MUST SIGN FOR YOU TO BE ABLE TO PARTICIPATE IN THE DUAL CREDIT

PROGRAM.

THIS WILL BE COMPLETED IN YOUR COUNSELOR’S OFFICE. STUDENTS CAN

CHOOSE TO HAVE THEIR SCORES SENT TO HINDS WHEN COMPLETING THEIR

SCORE REPORT ON THE ACT OR HE/SHE CAN HAVE THEM SENT WITH THEIR

TRANSCRIPT BY THE SCHOOL’S COUNSELOR

THIS WILL BE COMPLETED IN YOUR REGISTRAR’S OFFICE.

Dual Credit

Student

Admissions Checklist

THIS IS A DOCUMENT THAT BOTH THE STUDENT AND THE PARENT MUST SIGN

STATING THAT YOU UNDERSTAND THE CHARGES FOR PARTICIPATION IN THE

PROGRAM AND THAT YOU WILL NOT RECEIVE A PAPER BILL. YOU MUST GO TO

YOUR MY.HINDS ACCOUNT TO REVIEW YOUR BILL. SEND NO MONEY NOW.

Students - Please return this

form to your high school

guidance counselor along with

the required signed admissions

documents.

GUIDANCE COUNSELOR….

ALL ADMISSION DOCUMENTS SHOULD BE ATTACHED TO THIS FORM AND MAILED TO

HINDS COMMUNITY COLLEGE, OFFICE OF DUAL CREDIT, PO BOX 1100, RAYMOND, MS

39154

Student’s Name

_________________________

Student’s Hinds ID Number

_________________________

FERPA WaiverTHIS "STUDENT AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION"DOCUMENT MUST BE COMPLETED BY THE STUDENT SO THAT PARENTS/GUARDIANS CAN HAVE LEGAL ACCESS TO HIS/HER HINDS RECORD . BE SURE TO INCLUDE ALL SUCH PERSONS TO WHOM YOU WISH TO GRANT THIS PERMISSION.

Dual Credit Student/Parent Course Agreement

As a dual credit student, I will be enrolled both in my high school and Hinds Community College simultaneously. I understand and agree to following:

1. I understand I must meet admission requirements to the college in order to be admitted, and I must meet course placement requirements to be registered to certain college courses.

2. After admittance to the college, I understand Hinds CC will register me into the college courses in which my high school recommends and, at that time, I will become an enrolled student of Hinds Community College.

3. As an enrolled student of Hinds Community College, I agree to abide by all college policy and procedures as stated in both the college catalog and student handbook found on the college website at www.hindscc.edu

4. I understand I will have a My.Hinds student account where I can view and monitor important information such as my class schedule, grades, view and pay balance, and withdrawals. Log in using instructions at my.hindscc.edu

5. I understand that any Hinds Community College courses I take at my high school are both for high school credit and college credit and that I will receive a high school grade and a college grade.

6. I understand my high school may have a different grading scale than Hinds Community College; therefore, my high school grade and college grade could differ.

7. I understand the college grades I receive for any Hinds CC courses will go on my permanent college transcript.

8. I understand that I may withdraw from a Hinds CC course during the designated college withdrawal dates with permission from my counselor, and I must follow the college withdrawal procedure outlined in the student handbook.

9. I understand a course withdrawal will still appear on my permanent college transcript as hours attempted, but I will not receive a letter grade.

10. I understand that at this time Hinds CC offers free tuition for dual credit courses taken at my high school only, but I am required to pay a non-refundable $100 Dual Credit Program Participation Fee each term I enroll as a dual credit student.

11. I understand if I choose to enroll in a Hinds CC course on a Hinds campus or in traditional Hinds CC online courses, I will be subject to normal college tuition and fees.

12. I understand that I am responsible to pay my balance IMMEDIATELY after I am registered and that, if I do not pay, I will incur a late payment fee.

13. I understand that I will not be able to re-enroll at Hinds CC for another term unless my balance is paid in full.

14. I understand that my college transcript will not be released unless my balance is paid in full.

15. I understand that Hinds cannot release my college transcript to me or another institution until proof of high school graduation is shown by submitting an official high school transcript.

16. I understand that I will be required to purchase a college textbook and any supplemental learning aides, if applicable, for dual credit courses if my high school does not provide these.

17. I understand that Hinds Community College complies with the Family Education Rights and Privacy Act 1974 (FERPA) which gives students the right to control who views their confidential records. For parents to access these records, students must sign a FERPA waiver.

Print Name_____________________________________Student Signature___________________________________ Social Security Number____________\___________\_____________ Date___________________________________

As a parent/guardian of a dual credit student, I understand my child will be enrolled as a student of Hinds Community College and must abide by all college policies. Parent /Guardian Signature ____________________________________________Date________________________ Non-Discrimination Policy: Hinds Community College offers equal education and employment opportunities and does not discriminate on the basis of race, color, national origin, religion, sex, age, disability or veteran status in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Dr. Debra Mays-Jackson, Vice President for Administrative Services, 34175 Hwy 18, Utica, MS 39175; 601.885.7002

Rev. 2/17

Student’s Hinds ID Number

____________________

Dual Credit Student/Parent Participation Fee Agreement

As a dual credit student enrolled at my high school and Hinds Community College, I understand that I am responsible for my dual credit participation fee of $100. I understand that this payment is due IMMEDIATELY upon registration into the course(s). I understand that I will incur a $30 late fee if my payment is not received within four (4) weeks after the first day of class. I understand that I may pay my balance the following ways:

1. Payment through my.hinds account

2. Mail in a check or money order (must have student ID number on these forms of payment) a. Hinds Community College

Business Office PO Box 1100 Raymond, MS 39154

3. Pay by phone: (601) 857 – 3205

4. Pay in person at a Hinds Community College location I understand that I may set up a payment plan online through My.Hinds; however, I will be charged a $25 service fee. I understand that I will not be allowed to register in dual credit courses the following term if I owe a balance to the college. I understand that in order for my official Hinds Community College transcript to be released, I must have a $0 balance. Print Name_____________________________________Student Signature___________________________________ Hinds ID Number____________________________________ Social Security Number____________\___________\_____________ Date___________________________________

As a parent/guardian of a dual credit student, I understand my child will be enrolled as a student of Hinds Community College and must abide by all college policies. Parent /Guardian Signature ____________________________________________Date________________________

Non-Discrimination Policy: Hinds Community College offers equal education and employment opportunities and does not discriminate on the basis of race, color, national origin, religion, sex, age, disability or veteran status in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Dr. Debra Mays-Jackson, Vice President for Administrative Services, 34175 Hwy 18, Utica, MS 39175; 601.885.7002

Rev. 2/17

1. 2. 3.

State: Zip:

Date:

Date:

Date:

Received by: Copy given to student:Campus:

Received in District Admissions Office by:

Student's Name:

Address:

ID Number:

City:

Student Signature:

In order to assist me with my educational goals, I hereby authorize Hinds Community College to release my

personally identifiable college records to:

Hinds Community CollegeOffice of Admissions and Records

Waiver of Rights to Privacy of Records (FERPA)

(Name) (Name) (Name)

(Address) (Address) (Address)

I understand that by signing this authorization, I am waiving my rights of nondisclosure of the selected records under

federal law only to the person(s) specifically listed above. This release does not permit the disclosure of these

records to any other persons or entities without my written consent.

(City, State, Zip) (City, State, Zip) (City, State, Zip)

(Relationship to Student) (Relationship to Student) (Relationship to Student)

I authorize this release for :

Academic Records (attendance, grades/GPA)

Student Affairs Records (conduct/disciplinary, housing)

Financial Information (awards, disbursements, eligibility, financial aid academic progress status, charges, payments, past

due amounts, collection activity)

Disability Services

Notice of Non-discrimination Statement: In compliance with the following: Title VI of the Civil Rights Act of 1964, Title IX, Education Amendments of 1972 of the Higher Education Act, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 and other applicable Federal and State Acts, Hinds Community College offers equal education and employment opportunities and does not discriminate on the basis of race, color, national origin, religion, sex, age, disability or veteran status in its educational programs and activities. The following persons have been designated to handle inquiries regarding the non-discrimination policies:

Dr. Debra Mays-Jackson, Vice President for Administrative Services Dr. Tyrone Jackson, Associate Vice President for34175 Hwy. 18 Student Services & Title IX CoordinatorUtica, MS 39175 Box 1100 Raymond Campus (Denton Hall 221)601.885.7002 Raymond, MS 39154

601.857.3232titleIX@hindscc.edu

Edited 9/8/16