Admissions & Records
College of the Siskiyous, 800 College Ave., Weed, CA 96094
Phone: (530) 938-5500 - Fax: (530) 938-5367 Email:
Special Studies Petition (2929)
AP 4101; Title 5 - 55230
Special Studies courses are offered by the College of the Siskiyous to provide capable students with experience in
laboratory assistance, development of a research project, or supervised study in an area of special interest to the student.
The number of units which may be earned can be arranged by the student and instructor depending on the amount of
time that the student is able to devote to the activities of the course, up to a maximum of two units per semester (Carnegie
units). The student may not accumulate more than four units of Special Studies credit.
1. Complete this form with your intended instructor.
2. The instructor submits the form to the appropriate Dean for approval.
3. The Dean forwards it to scheduling for a course recognition number.
4. The student then submits the form to Admissions & Records. If the student is not registered in any other courses
he/she will need to complete an Enrollment/Registration form.
Step 1: To be Completed by Student
Last Name: First Name: MI:
Date of Birth: Student ID#: S00 or SSN:
COS Email: Phone:
Mailing Address:
City: State: Zip Code:
Semester to be taken: Summer Fall Winter Spring Year: 20
Are you currently registered for courses this semester? Yes No
Special Studies Subject Area Units (max 2):
Example *1=54 hrs / 2=56-98 hrs
Reasons you plan to enroll in the Special Studies (2929) course specified above.
What is your prior academic experience in the above subject area?
Please describe in detail the project which you plan to undertake if you are permitted to enroll in a Special
Studies (2929) course (attach extra sheets if necessary):
How many hours will be required to complete the above project:
Student Signature: Date:
Step 2: To be Completed by Instructor
Does the student meet the prerequisites as stated on Approved Course Outline: Yes No
If no, and you are approving, please complete a “Petition for Waiver of Requirement for Prerequisite” form.
Individual Course Objectives (please list):
SLO Assessment: Describe in detail how student grade will be determined.
I understand that I need to submit both census and final grades for the above class.
Instructor Signature: Date:
Dean Signature: Date:
Petition Approved: Yes No Date:
Course Start Date: Census Date: End Date:
Enrolled by: Date: