High Scholars Dual Enrollment Application for Online Admission

Welcome to the online application for the High Scholars Dual Enrollment Program at Belhaven University in Jackson, Mississippi.  Please completely fill out this application and click the SUBMIT button at the bottom of the page to get your college application moving.  An admission counselor will contact you upon receipt of your online form.  Please note that information on your application fee payment will be provided once your online application is submitted.  We are excited that you are applying to Belhaven and we look forward to serving you as you grow academically and spiritually.  Required fields are marked with an asterisk (*).

Mother's First Name: *
Father's First Name: *
Parent Last Name: *
Student's First Name: *
Student's Last Name: *
Address Line 1: *
Address Line 2:  
Address Line 3:  
City: *
Country: * United States   Other Country

High School Information
Name of High School:  
Graduation Date:   mm/dd/yyyy
High School GPA:  

Test Scores
ACT Score:  
SAT Score:  
Expected Year of Enrollment: *
Expected Term of Enrollment: *
Preferred Section: *
Second Choice For Section: *
Anticipated College Major: *

Please feel free to send a separate listing of extracurricular, community, religious or individual activities to admission@belhaven.edu.

Miscellaneous Information
Are you currently or have you ever
been dual enrolled in College?
* Yes   No
If yes, where?  
When will you finish there?   mm/dd/yyyy
How did you hear about Belhaven? *
Other Source:  
Religious Affiliation:  
Church Name:  
Hometown Newspaper:  

Previous College Information

Please enter information where appropriate.  List all institutions attended (most recent institution first).  Transcripts of all previous work MUST be submitted to the Admission Office.  If you will not attend any college(s) before coming to Belhaven, leave this section blank.

Most Recent College Attended
College or Institution Name:  
Location (City, State):  
Date First Enrolled:   mm/dd/yyyy
Date Last Enrolled:   mm/dd/yyyy
Previous College Attended
College or Institution Name:  
Location (City, State):  
Date First Enrolled:   mm/dd/yyyy
Date Last Enrolled:   mm/dd/yyyy
Names of Other Colleges Attended:

Belhaven Relationships

If applicable, list up to two relatives who are alumni or current students at Belhaven.

Relationship 1
Last Name:  
First Name:  
Relationship to you:  
Relationship 2
Last Name:  
First Name:  
Relationship to you:  

For Federal Reporting Purposes

The following information is optional and does not affect the admission process.  It is used for statistical purposes and to provide information required by the U.S. Department of Education in accordance with applicable federal regulations.  An answer in each category would be appreciated.

Select Country of Birth:  

Ethnicity and Race Information Marital Status
Are you of Hispanic/Latino ethnicity or descent?

Select one or more races with which you identify yourself:
  American Indian or Alaska Native
  Black or African American
  Native Hawaiian or Other Pacific Islander

Electronic Signature
Electronic Signature Required:

I hereby affirm to the best of my knowledge that all information on this form is complete and accurate and that any omission or misrepresentation may result in denial to the program, loss of credits, and/or dismissal from Belhaven University.  I authorize Belhaven University representatives to request and receive from all schools my child has previously attended (or is attending) copies of my child's academic records upon filling out the transcript request form.  If enrolled, my child agrees to abide by all the policies of Belhaven University including, but not limited to, those represented in the catalogue and student handbook; I also give Belhaven University permission to send and supply news, photos and honors to my child's hometown newspaper and college publications.

Belhaven University is committed to a policy of non-discrimination on the basis of race, color, sex, religion, handicap, age, or national/ethnic origin.

Parents:  To sign, type your full name: *
Today's Date *
Agreed acts as your signature * Yes   No
Enter the numerical value of ten minus three. *