Office of Enrollment Services, 4000 Lancaster Drive NE, Building 2, Room 200,Salem, OR
Mailing Address: PO Box 14007, Salem, OR 97309-7070
Phone: 503.399.5001 Email: registrar@chemeketa.edu
Chemeketa Community College is an equal opportunity/affirmative action employer and educational institution. To request this publication in an
alternative format, please call 503.399.5192.
8/6/2015 s:\registrar\forms\65+ tuition waiver & audit request.docx chemeketa.edu
65+ Tuition Waiver & Audit Request
The tuition waiver benefit will not apply unless registration is processed through this form.
1. Eligibility requirements:
a. Must be 65 years or older AND a Oregon resident as of the start of the term
b. As of 2
nd
week of the course the instructor & department must verify space is available in the course
c. Lower-division 100 or 200 level collegiate credit courses qualify for the waiver (see catalog
pg 146)
d. Course prerequisites must be satisfied prior to enrollment
e. The tuition waiver can be used to cover a maximum cost of 8 credits per term
f. The student is responsible for paying all course fees
g. Forms are accepted no earlier than the 2
nd
week of the term and no later than the 4
th
week
h. Do NOT
enroll in the course online via My Chemeketa, that will disqualify you from receiving the waiver
2. About Audited Courses:
a. Grades and credits are not granted at any time for audited courses
b. Audited courses will not satisfy graduation, veteran’s benefit, or financial aid requirements
c. Auditing students participate in the course to the degree that they and the instructor agree upon
3. Steps to request a 65+ Tuition Waiver and Audit Request:
a. If you are not already a Chemeketa student you must apply for
admission: http://applyonline.chemeketa.edu
b. Complete the entire form & obtain the required instructor and departmental approval signatures
c. Submit the completed form to Enrollment Services, Salem Campus, Building 2, Room 200
Student ID (K#): Birth Date: - -
Name: _________________________________________________________________________________________
Last, First, Middle
Address: ________________________________________________________________________________________
Street, City, State Zip
Phone Number with Area Code: Cell Phone: ______________________ Home Phone: _______________________
Term:_______________________
Term & Year (e.g. Fall 2015)
Course Subject & #:______________________ CRN:________________
(e.g. ART 101)
Instructor:___________________________________________ Department:__________________________________
Signature Date Signature Date
Course Subject & #:______________________ CRN:________________
(e.g. ART 101)
Instructor:___________________________________________ Department:__________________________________
Signature Date Signature Date
PAYMENT IS DUE WITHIN 10 DAYS OF REGISTRATION
I understand that any unpaid tuition and fees and other charges will be considered an educational loan between me and Chemeketa Community
College that is non-dischargeable under Section 523(a)(8) of the US Bankruptcy Code. I further understand that if I fail to pay my account balance
in full, late charges and any subsequent collection charges may be added to my account balance due. In case legal action is instituted to collect
on my account, I agree to pay in addition to the costs and disbursements, provided by law, such additional sums as a court of law may determine
as reasonable for attorney’s fees and court costs. Oregon State law applies to any dispute over payment.
Student Signature_________________________________________________________ Date___________________
Office Use Only
Registration Code: RO Processed by: ______________ Date: ___________ Fees Paid: Yes No
Waiver Approved: Yes No Waiver Input by:___________________ Date:_____________
K
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