Online Course Access Registration
(Students needing to register for online courses)

Student Information
First Name:
*
 
MI:

       
Last Name:
*
 
Birthday:
*
 
Address:
*
 
City:
*
 
State:
*
 
Zip:
*
 
Home Phone:(xxx-xxx-xxxx)


 
Cell Phone:(xxx-xxx-xxxx)
*
 
 
Email Address:
*
 
 
Gender:*                  
 
USCitizen:*                          
 
Hispanic/Latino:*                      
 
Ethnicity/Race:*





High School Information
Home High School:
*
 
High School Graduation Year:
*(4 digit year)
  
DMACC Class Schedule Information                
Semester:*   
 
Year:
     
Choice# Course Title Subject Course
Course-1:    *
Course-2:   
Course-3:   
Course-4:   
Comments:
     
Authorization for Registration
* By checking this box I understand I am enrolling in DMACC credit course(s). An official DMACC transcript will be generated and become a part of my permanent academic record. I also understand this request will be routed to my High School Instructional Coach for final approval.