Dual Enrollment Gateway - Account & Registration Request

<h2>Personal Information</h2><p class="alert alert-secondary">This information will be included in your Gallatin College student record.</p>

Legal First Name*

Legal Last Name*

Legal Middle Name or Initial

I have previously enrolled in or completed a dual enrollment course or earned college credit though Gallatin College/Montana State University Bozeman*

Date of Birth*

Enter date as mm/dd/yyyy

Email*

Confirm Email*

Gallatin College will send important notifications to this email address, so please use an email that you check frequently.

<h2>Address/Contact Information</h2>

Address Line 1*

Address Line 2

City*

State

Zip Code*

County*

Country of Citizenship*

Cell Phone Number (10-digit)*

10 digits (i.e. 5551231234). You will receive texts to the cell number provided. If you wish to OPT OUT of texting, please contact the Gallatin College Dual Enrollment Coordinator.

Home Phone Number (10-digit)*

10 digits (i.e. 5551231234). If you do not have a home phone, please re-enter cell phone number.

<h2>Academic Information</h2>

High School*

My high school is not listed.

Please enter your high school name

High School Graduation Month and Year*

As mm/yyyy

<h2>Parent Information</h2>

Relationship*

First Name*

Last Name*

Email*

Address Line 1*

Address Line 2

City*

State*

Zip/Postal Code*

Country*

Parent Cell Phone Number (10-digit)*

10 digits (i.e. 5551231234)

<h2>Safety and Security</h2>

An affirmative ("Yes") response to any of these questions will not automatically prevent admission, but you may be asked to provide additional information. This information will be reviewed by a campus committee to ensure campus safety. Any falsification or omission of data may result in a denial of admission or dismissal.

Have you ever been convicted of a felony (please include instances of deferred sentencing)?*

Yes

No

A felony in Montana State Law is defined as a crime for which more than one year in prison may be imposed.

Have you ever been subjected to court-ordered confinement for threatening or causing physical or emotional injury to person or property?*

Yes

No

Have you ever been disciplined by, suspended from, or placed on probation at any educational institution for nonacademic reasons?*

Yes

No

Suspension is defined as a sanction imposed for disciplinary reasons that results in a student leaving school for a fixed time period, less than permanently. Dismissal from a college for disciplinary reasons is defined as permanent separation from an institution of higher education on the basis of conduct or behavior.

Have you ever been required to register as a sexual or violent offender?*

Yes

No

If you answered yes to any of these questions, please explain

<h2>Voluntary Statistical Information</h2>

Gender

Race/Ethnicity

Hispanic

American Indian

Asian

Black

Native Hawaiian or Pacific Islander

White

Other