Westfield State Dual Enrollment Application

Westfield State Dual Enrollment Application
Please complete this Dual Enrollment application fully. Once submitted, the program coordinator will reach out for additional information, and to update you on the progress of your application. Thank you for your interest in Dual Enrollment opportunities at Westfield State University!
Student Information
Name*

First NameMiddle InitialLast Name
Preferred Name (Optional)

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleNon-BinaryOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email Address*
example@example.com
Parent/ Guardian Information
Name*

First NameLast Name
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Email Address*
example@example.com
High School Information
Name of High School*
SASID ( Student ID available at Guidance Office or your High School Transcript)*
High School Phone Number*
Please enter a valid phone number.
School Counselor Name*

First NameLast Name
School Counselor Email*
example@example.com
Grade while taking this course(s)*

FreshmanSophomoreJuniorSenior
Expected year of graduation*
Academic Term*

Winter 2025Spring 2025
Academic Year*
Major of Interest
High School Transcript*

Cancelof
Please answer the following questions for data reporting purposes and to assist us in providing equitable access to CDEP to grant funding. For the first question, please go to the Massachusetts Department of Elementary and Secondary Education webpage to learn more.
Are you participating in the following programs? Please select all that apply:*

SNAPTAFDCDCFMassHealthNone
Are you considered by the state as "economically disadvantaged"?*

YesNo
Did a parent graduate from college?*

YesNo
Do you speak a language(s) other than English at home?*

YesNo
If yes, which language(s) do you speak?
Are you interested in Science, Technology, Engineering or Math (STEM disciplines)?*

YesNo
Ethnic/ Racial Background (Choose all that apply)*

American Indian or Alaskan NativeNative Hawaiian or other Pacific IslanderBlack or African AmericanAsianCape VerdeanWhiteOther
(Choose one)*

Hispanic or LatinoNon-Hispanic or Latino
Course Selection
Please fill in your course selection information below. Please select your first, second, and third choice class. If you need to view the list of classes available, please click the link below:

Winter 2025

Spring 2025

Course Information EXAMPLE:

ECON 0101-501(11090) CR: (3.0)

Course Name: ECON 0101

Section #: 501

CRN #: 11090

# of Credits: 3.0

*Please do not use the example to fill out course information.*
Signatures
Student Signature*

First NameLast Name
Signature*

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Parent/ Guardian Signature

First NameLast Name
Signature

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Should be Empty:

Westfield State Dual Enrollment Application

Student Information

Parent/ Guardian Information

High School Information

Course Selection

Signatures