Student Affairs—Admissions/Records/Enrollment Services 4501 Amnicola Hwy., Chattanooga, TN 37406-1097

Phone: 423-697-4401 Fax: 423-697-4709 www.chattanoogastate.edu

Name (please print): Last First Middle

Date of Birth: / / Age: Student ID (A Number): Address: City: State: Zip: Home Phone: Cell Phone: Email: I plan to attend my first class at MTSU : Fall 20 Spring 20 Summer 20 MTSU Intended Major: Student Signature: Date: Authorization to release info

Parent/Guardian Signature: Date: Only required if participant is under the age of 18

Please return completed form to ChSCC’s Advising office.

ChSCC Student Support Specialist: Date:

By signing this statement of intent, you are indicating your intention to participate in the MTSU and ChSCC Dual Admission Program. As a

participant in this program, you are subject to the same admission, matriculation, disciplinary and degree requirements governing all

other MTSU and ChSCC students. This is an admissions agreement which does not include any particular program or major. This

Statement of Intent to Participate will also serve as a Release of Information that authorizes the institutions to share appropriate

admission, financial, academic and advising information concerning the enrollment and performance of the student. You are agreeing to

abide by the policies and procedures of the Dual Admissions Program, ChSCC and MTSU .

Academic Advising:

Knowing the important role that academic advising plays in a student’s success, counselors and advisors at ChSCC and MTSU are available

to assist you in tailoring your program of study to meet your educational goals. If you change your major, you will need to notify your

academic advisor at ChSCC and MTSU .