Dual Enrollment Parent/Guardian Authorization

Please read this page in its entirety. Your electronic signature at the bottom of this page is required for your student to be admitted to Austin Peay State University's Dual Enrollment program. Please contact our office at 931-221-7175 or e-mail govnow@apsu.edu if you have any questions.

(1) Meningococcal Meningitis and Hepatitis B Notification Acknowledgement for Dual Enrollment Students

The General Assembly of the State of Tennessee mandates that each public or private postsecondary institution in the state provide information concerning Hepatitis B infection to all students entering the institution for the first time. Those students who will be living in on-campus housing for the first time must also be informed about the risk of Meningococcal Meningitis infection. The required information below includes the risk factors and dangers of each disease as well as information on the availability and effectiveness of the respective vaccines for persons who are at-risk for the diseases. The information concerning these diseases is from the Centers for Disease Control and the American College Health Association.

A. Hepatitis B (HBV)
Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver failure, and even death. The disease is transmitted by blood and or body fluids and many people will have no symptoms when they develop the disease. The primary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease is completely preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are required for optimal protection. Missed doses may still be sought to complete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases.

B. Meningococcal Meningitis
Meningococcal disease is a rare, but potentially fatal, bacterial infection, expressed as either meningitis (infection of the membranes surrounding the brain and spinal cord) or meningococcemia (bacteria in the blood). Meningococcal disease strikes about 3,000 Americans each year and is responsible for about 300 deaths annually. The disease is spread by airborne transmission, primarily by coughing. The disease can onset very quickly and without warning. Rapid intervention and treatment is required to avoid serious illness and or death. There are five different subtypes (called sereogroups) of the bacterium that causes Meningococcal Meningitis. The current vaccine does not stimulate protective antibodies to Serogroups B, but it does protect against the most common strains of the disease, including serogroups A, C, Y and W-135. The duration of protection is approximately 3 - 5 years. The vaccine is very safe and adverse reactions are mild and infrequent, consisting primarily of redness and pain at the site of injection lasting up to two days. The Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control and Prevention (CDC) recommends that college freshmen (particularly those who live in dormitories or residence halls) be informed about meningococcal disease and the benefits of vaccination and those students who wish to reduce their risk for meningococcal disease be immunized. Other undergraduate students who wish to reduce their risk for meningococcal disease may also choose to be vaccinated.

For more information about Meningococcal Meningitis and Hepatitis B disease and vaccine, please contact your local health care provider or consult the Center for Disease Control and Prevention Web site.

(2) Financial Concerns and Obligations for Dual Enrollment Students

1. Students must submit complete applications for the Tennessee Dual Enrollment Grant (DEG) by posted deadlines.

2. Students and parents both understand how using DEG funding for courses 5-10 will impact their HOPE scholarship.

3. Students and parents both understand the student must maintain a college GPA of at least 2.75 to continue receiving DEG funding in subsequent dual enrollment semesters.

4. Students taking more than one course in the same semester must meet HOPE eligibility requirements to receive funding for the second and third course (minimum ACT composite score of 21 OR minimum high school GPA of 3.0; home school students must have the ACT score of 21).

5. Students must have been a TN (or Ft. Campbell, KY) resident for at least one year at the time of enrollment to receive funding.

6. Students taking courses in the same semester with two different institutions will provide any required documentation in order to participate in the consortium agreement between those institutions, which includes having college transcripts sent at the beginning of each semester.

(3) Dual Enrollment Fee Discount or Waiver

If your student qualifies for a fee discount based on your employment, please submit the appropriate form each semester when your student registers. Teacher dependent discount forms should be sent to walkerj@apsu.edu. State dependent discount forms should be sent to ogburng@apsu.edu.

Click here to view those forms.

(4) Permission and Agreement

As parent/guardian of the student named below, my signature on this form, certifies that I have read and understand the early admission and concurrent (dual/joint enrollment, academically talented) enrollment policies, including:

Program and course requirements
My student must maintain an APSU GPA of 2.75 to remain in the dual enrollment program for subsequent semesters while in high school. If their APSU GPA falls below 2.75 and they have a 3.0 high school GPA, they may reapply for admission.
Financial obligations, lottery grant regulations, discount/waiver eligibility: I understand that I am responsible for the payment of any tuition or fees not covered by the dual enrollment grant.
Privacy and confidentiality regulations: Dual Enrollment student information is protected by FERPA. Austin Peay State University and the student's high school may exchange information, but information available to parents is limited. Please see our Student Information page here. Submission of a FERPA form is strongly recommended.

Your Student's First Name:*

Your Student's Last Name:*

Your Student's Date of Birth:*

Hepatitis B (HBV) - please select the appropriate statement as it refers to your student:*

Date of completion of the Hepatitis B vaccination series (MMDDYY):*If your student has not completed the vaccination series, please type "NA".

Meningococcal Meningitis - please select the appropriate statement as it refers to your student:*

Date of completion of the Meningococcal Meningitis vaccine (MMDDYY):*If your student has not received the vaccine, please type "NA".

ELECTRONIC SIGNATURE ACKNOWLEDGEMENT AND CERTIFICATION OF UNDERSTANDING

I hereby give permission for my son/daughter to enter the Austin Peay Dual Enrollment program, and I understand the conditions regarding eligibility, program requirements and financial obligations.

ELECTRONIC SIGNATURE. This Acknowledgement and Certification of Understanding ("Acknowledgement") is to let you know that by submitting an electronic signature, you are providing an electronic mark, that is held to the same standard as a legally binding equivalent of a handwritten signature provided by you. For purposes of the acknowledgement, a digital mark is considered a typed legal First and Last name (legal name may include middle name, initial or suffix) followed by the typed date. Any document requiring an electronic signature may contain a signature acknowledgment statement provided in the same area requiring the electronic signature.

AGREEMENT: By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

CERTIFICATION OF UNDERSTANDING: I also understand, acknowledge, agree and certify that:

• I accept my responsibilities in the use of electronic signatures as described on this form.

Parent/Guardian E-Signature*Please include your first and last name.

Date and Time of Acknowledgement*

Your phone number:*

Austin Peay State University does not discriminate on the basis of race, color, religion, creed, national origin, sex, sexual orientation, gender identity/expression, disability, age, status as a protected veteran, genetic information, or any other legally protected class with respect to all employment, programs and activities sponsored by APSU. http://www.apsu.edu/policy. Policy 6:003 AP90/9-17/250