Limited Special Admission (LSA) Program

Application for College Credit Admission

LSA is a college program for high school seniors who have completed State of Florida
graduation requirements prior to their commencement.
It is NOT dual enrollment and does NOT earn high school credit.

Students enrolled in a public or private high school or home school may enroll in a maximum of 12 hours of college
credit coursework with parental consent, if they can document that they have completed all requirements for high
school graduation. Students enrolling under this provision must qualify for college level coursework through
assessment, and are responsible for all tuition and fees.

PERSONAL INFORMATION

Please print in ink and complete in full.

Name____________________________________________________________________________________________
Last

First

Middle

Social Security Number_______________________ Home Telephone (

Previous Name If Any

)__________________________________

*In compliance with Florida Statute 119.071(5), Florida State College at Jacksonville issues this notification regarding the purpose of the collection and use of Social Security
numbers. Florida State College will collect your Social Security Number (SSN) for record identification, state and federal reporting. Providing your SSN on this application means
that you consent to the use of your number in the manner described. If you choose not to provide your SSN, you will be provided an alternate identification number. All Social
Security Numbers are protected by Federal regulations and are not to be released to unauthorized parties. Read more about the collection and use of social security numbers
(http://www.fscj.edu/ssn).

Mailing Address___________________________________________________________________________________
Number and Street or P.O. Box

Apt. #

________________________________________________________ E-Mail___________________________________
City

State

ZIP Code

Emergency Contact_________________________ Telephone (

)___________________(

)_________________

Home

Gender: Female Male

Work

Primary Language: English Spanish Other_____________________________

Date of Birth_____/_____/_____ Age______ Grade Level_______ Country of Birth__________________________

Are you a U.S. citizen? Yes No (If no, please attach a legible copy of your Visa and I-94 card or resident alien card.)
Name of high school ____________________City _____________ Anticipated graduation date: Month ____Year___
Alternatively: Location GED taken within past 3 months__________________Date taken: Month______Year______
Were you previously enrolled as a Dual Enrollment Student at FSCJ? Yes No
Information submitted in this section of the application is voluntary and will not be used in the admission process.
Are you Hispanic/Latino? Yes No Prefer Not to Disclose.
Please select the racial category or categories with which you most closely identify. Check as many as apply.
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Prefer Not to Disclose.

ENROLLMENT PLANS
College course(s) for which this application is intended:

Term

College Course #

Ref. #

For Office Use:

Residency: 3 Out-of-State (with residency affidavit)
Basis of Admission: C-N Limited Special Admission-New
Program Objective: 3450 Limited Special Admission

Course Title

or
or

Location of Class

Residency 1 or 2 (with residency affidavit & documentation)

C-R Limited Special Admissions-Readmit

Please complete reverse side of form.

(April, 2013, blue form)

TEST SCORES
To qualify for enrollment in the Limited Special Admission program, official test scores must be on file or attached.
Please mark one of the following:
SAT-Attach a copy of test results (less than two years old.)
ACT- Attach a copy of test results (less than two years old.)
PERT- Scores must be on file at College assessment services department.

PARENT/GUARDIAN AGREEMENT To be completed by Parent/Guardian

Name of Applicant:__________________________________________ has my permission to enroll at Florida State
College in the Limited Special Admission program.
FLORIDA RESIDENCY-I understand that in order to qualify for Florida residency for tuition purposes for the term for
which this application is submitted I must complete a Residency Affidavit prior to the beginning of the term. I understand
that if I do not submit a Residency Affidavit with supporting documentation, the applicant will not be eligible for in-state
tuition rates.
Parent/Legal Guardian Signature _____________________________________________ Date_____________________

STUDENT AGREEMENT

To be completed by Student

I hereby apply for admission to Florida State College at Jacksonville and agree to abide by all rules and regulations of
the College.

FLORIDA RESIDENCY-I understand that in order to qualify for Florida residency for tuition purposes for the term for
which this application is submitted I must complete a Residency Affidavit prior to the beginning of the term. I
understand that if I do not submit a Residency Affidavit with supporting documentation, I will not be eligible for in-state
tuition rates.

I understand that to continue enrollment at Florida State College at Jacksonville as a degree seeking student after
graduation, I must submit:
o
o
o

An official copy of my final high school transcript, GED passing scores, or home school affidavit. Please note: we
will automatically request your high school transcript if you graduated from a public school in Duval or Clay
counties.
An official college transcript (if applicable) from each college attended, and
Log into my online student portal Connections and select the My Programs of Study/Degree Audit link to request a
Program of Study (POS) change.

I have checked this application for errors and certify that the information is accurate and complete.

Applicant Signature ________________________________________________________ Date_____________________

FloridaStateCollegeatJacksonvilleprovidesequalaccesstoeducation,employment,programs,servicesandactivitiesanddoesnotdiscriminateonthebasisofage,race,color,national
origin,sex,disability,religiousbelief,ormaritalstatus.TheCollegeEquityOfficerhasbeendesignatedtohandleinquiriesregardingthenondiscriminationpoliciesandmaybecontactedat
equityofficer@fscj.edu.FloridaStateCollegeatJacksonvilleisamemberoftheFloridaCollegeSystemandisnotaffiliatedwithanyotherpublicorprivateuniversityorcollegeinFloridaor
elsewhere.FloridaStateCollegeatJacksonvilleisaccreditedbytheSouthernAssociationofCollegesandSchoolsCommissiononCollegestoawardthebaccalaureateandassociatedegree.
Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 300334097, or call (404) 6794500 for questions about the accreditation of Florida State College at
Jacksonville.TheCommissionistobecontactedonlyifthereisevidencethatappearstosupportaninstitutionssignificantnoncompliancewitharequirementorstandard.