Dual Enrollment - Cheektowaga High School

What is the name of your High School? (If it is not listed, please stop & email [email protected] for the link to the correct application).*

Cheektowaga High School

Have ever applied to Trocaire College?*

Yes
No

Student Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Country of Birth*

Date of Birth

Student Social Security Number*

Student Email Address*

Information below is needed for Federal Government Regulations. What is your ethnicity?*

Hispanic or Latino
Not Hispanic or Latino

What is your race?*

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Parent or Guardian name*

Parent or Guardian Phone Number*

Parent or Guardian Email Address*

Emergency Contact (Name, relationship, phone #)*

Enrollment semester*

Spring 2025

I am requesting to take the following course(s) at Trocaire College below*

PH205 Ethics in Healthcare (section DCHK)

Financial Liability Agreement*

I accept

“I understand that upon registration for any class or service at Trocaire College, I am responsible for payment of all tuition, fees, and other associated costs assessed as a result of my registration and/or receipt of services. In addition, I authorize Trocaire College and its agents and contractors to contact me at my current and any future cellular phone number(s), email address(es), or wireless device(s) regarding my delinquent student account(s)/loan(s), any other debt I owe to Trocaire College, or to receive general information from Trocaire College. I authorize Trocaire College and its agents and contractors to use automated telephone dialing equipment, artificial or prerecorded voice or text messages, and personal calls and emails, in their efforts to contact me. Furthermore, I understand that I may withdraw my consent to call my cellular telephone by submitting my request in writing to the applicable contractor or agent contacting me on behalf of Trocaire College.
I further understand and agree that my registration and acceptance of these terms constitutes a promissory note agreement (i.e., a financial obligation in the form of an educational loan as defined by the U.S. Bankruptcy Code in which Trocaire College is providing me educational services).
I understand and agree that if for any reason I drop/withdraw, or I am dropped/withdrawn by administrative College personnel, from any or all of the classes for which I registered, I will be responsible for paying all or a portion of tuition and fees in accordance with the Trocaire College refund schedule. I understand that my failure to attend class or receive a bill does not absolve me of financial responsibility as described above.
I understand that my financial aid is contingent upon continued enrollment in and attendance of all classes upon which my financial aid eligibility was originally calculated. I must also meet and maintain all SAP, Satisfactory Academic Progress, standards. I acknowledge that based on federal regulations, some or all aid may be removed as a result of my withdrawal. I agree to pay any and all remaining charges associated with mandatory return of aid.”
Financial Hold
“I understand and agree that if I fail to pay my student account bill or any monies due to Trocaire College by the scheduled due date, a balance hold will be placed on my student account. The hold will prevent future class registration and the release of a diploma until the balance has been paid in full.”
Late Payment Charge
“I further understand and agree that if I fail to pay my student account bill or any monies due to Trocaire College by the scheduled due date and my account is not enrolled in a payment plan, I will be charged a late charge of 5% of the total balance due.”

Campus Health and Safety Compliance*

I accept

Trocaire College is committed to ensuring a healthy and safe campus community. The College reserves the authority and discretion to impose health and safety restrictions and regulations deemed appropriate (may include but not limited to vaccination, booster, and/or other health care related action) at any time, due to changes in local conditions and/or requirements imposed by Federal, State, or local authorities for its campus.

Certain employees, students, and volunteers at healthcare facilities, hospitals, or any external affiliate location may be subject to mandatory immunization and/or other healthcare related requirements pursuant to dictate their own requirements. Trocaire does not set or enforce those requirements. A student who is unwilling or unable to comply with such requirements may be excluded from certain course requirements (including clinical) that could impact matriculation.

Attestation: I have read, understand, and pledge compliance with the aforementioned declaration. Further, I understand that once this attestation is endorsed, via my signature, that I hold Trocaire College free of harm and liability resulting from activation of said declaration.

Student Consent*

I accept

I hereby certify that by selecting the “I Accept” button, I am signing this request form electronically and that my electronic signature is the same as my handwritten signature.

Parent Consent*

I accept

I hereby certify that by selecting the “I Accept” button, I am signing this request form electronically and that my electronic signature is the same as my handwritten signature.

Date

Dual Enrollment – Cheektowaga High School

Welcome to Trocaire College!

Registration is a three step process:

1. Submit the electronic application below.

2. Make check or money order payable to Trocaire College for $390 ($130 per credit hour). Please include student first & last name on check or money order.

3. Drop off the check or money order to the High School Student Services Office.

Payment must be received by January 21st to complete the course registration.

Dual Enrollment - Cheektowaga High School