Revised: 10/26/16
APPLICATION FOR INDIVIDUALIZED STUDY
I understand I am responsible for paying any and all fees when due as a result of being enrolled at Lewis-Clark State
College. Failure to make the required payment when due can result in late fees, collection and legal fees if the services of a
collection agency are employed, the inability to register for a future term, and/or withholding of a transcript.
Health insurance is required if total term credits equal 12 or more.
________________________________________________________________________________ _________________________________
LAST NAME FIRST NAME MI STUDENT ID/SSN STUDENT SIGNATURE
_______________________________________________________________________________________ _________________________
MAILING ADDRESS CITY ST ZIP PHONE NUMBER DATE
INST METHOD
(mark with X)
NUMBER OPTIONS ATTACHMENTS
Directed Study (DS:) 190 290 390 490 or catalog crse # _____ Syllabus
Service Learning (SL:) 193 293 393 493 or catalog crse # _____ None
Internship (IN:) 194 294 394 494 or catalog crse # _____ None
Practicum (PR:)
195 295 395 495 or catalog crse # _____ None
Research Assistantship (RA:) 199 299 399 499 or catalog crse # _____ Project Description
Please ensure the number you choose exists in the current college catalog before noting it on this form.
-
Individualized Study options are not available for a course during a term in which that course is already offered.
-
If this Individualized Study course will substitute for another course, a Course Substitution Form must be attached.
Application Approved ____Disapproved Reason Disapproved
Division Chairperson Date
_______
____________________ ___________
Registrar Date
COURSE INFORMATION
TERM
______________
YEAR ___________ LOCATION
(circle)
: ONC | CDA | Dist Learning
SUBJECT COURSE # # OF CREDITS
TITLE
(≤26 char incl spaces)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
If you plan to use an online component or alternate method, please circle the appropriate secondary method below.
SEC INST METHOD
(circle):
HYBF | WEB | TELR | TELS | LAB | CNL | None
FACULTY NAME
(printed)
FACULTY SIGN
ATURE DATE
Office
Use
Section
#
Initials
Date
CONTROLLER’S OFFICE ___ fee attached ___ no fee
__________________________________ ____________
Controller’s Office Staff Date
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