Fill - Free fillable Concurrent Enrollment Form 2009 (Cerritos College) PDF form

CERRITOSCOLLEGESpecialAdmit‐K‐10

th

CollegeBridge‐11

&12



ThismustbecompletedinBLUEorBLACKinkonly

Tobecompletedbystudent 

Name

Cerritos College ID Number:

Last  First Middle

SocialSecurityNumber:

DateofBirth:

Age:

TypeofInstitution: PublicSchool PrivateSchool HomeSchooled Other:

Telephone:

GradeLevel:

ForSummer:EnterthegradethatyouwillbeenteringinSept.

StudentSignature: Date:

Tobecompletedbyschoolprincipalorauthorizedofficial

SchoolOfficial:Icertifythattheabove‐namedstudentisacademicallyqualifiedforthecourse(s).Thestudentis:

 CurrentlyAttending NotAttendinganaccreditedprivateorpublicschoolandhasdistrictapprovaltoenrollin

Term:SpringSummerFallYear:________

Class# CourseName&No. Units

CerritosCollegeInstructor’sSignature

RequiredforK‐10

GradeStudentsonly

CumulativeGPA

____._____

SpecialAdmit

‐Spring/Fall/Summer‐Max.4units*CollegeBridge–Spring/Fall‐Max.8units*Summer‐Max.7units*

*Exceptionsmaybeconsidered.PleaseseeDeanofAdmissions,RecordsandServices–StephanieMurguia

SummerSessionOnly:Icertify,asprincipal,thatallstudentsrecommendedforSummer_______(yr.)meetallofthefollowingcriteria:

 Demonstratesadequatepreparationinthedisciplinetobestudied;

 Hasexhaustedallopportunitiestoenrollinthesameoranequivalentcourseathis/herschool;

 Complieswiththerequirementofallowingamax.of5%

inthetotalnumberofstudentsenrolledattheschool’sgradelevel.

Icertifythatthisstudentwouldbenefitfromadvancedscholasticorvocationalcourseworklistedabove.

SchoolofAttendance: ExpectedGraduationDate:

Counselor/PrincipalSignature:Date:

Tobecompletedbyparentorguardian

Igivemypermissionforemergencyfirstaidandtreatmentformyminorchild/legalward.Ialsogivemypermissionforher/himto

betreatedbyanurse,physicianandormentalhealthcounselorintheStudentHealth&WellnessCenterofCerritosCollege.

Iunderstandthatmychilddoesnotintendtoenrollinacollegecourse

(s)thatisnot

 specificallydesignedforstudentsunderthe

ageof18,andthatCerritosCollege acceptsnoresponsibilityforany  extraordinarysupervisionofstudentsless than18yearsof

age.Further,Iacceptfullresponsibilityformychild’sbehaviorwhilehe/sheisattendingCerritosCollege.Allcollegecourseworkis

governedbytheFamilyEducationRightsandPrivacyAc

t,whichprohibitsreleaseofacademicinformation.Iunder

standthatIwill

nothaveaccesstomychild’sacademicrecords(including,butnotlimitedtogradesandtranscripts)withouthis/herwrittencon‐

sent‐regardlessofage.

Ihavereadandunderstandtheattachedinformation.

Parent/GuardianSignature:Date:

AdmissionsStaffUseOnly:

Engl/Read/MathTests UnitLimit

StudentGroup EquationVariables

TermActivated Minor’sHealthForm





DeanofA,R,&S:Date:

Processedby:Date:

Waiver:  Approved Denied

ReceivedSubstandardGrade

Updated DB: 3/26/10

Special Admit K-10

/College Bridge 11

&12

Title 2, Chapter 5, Article 1, Section 48800 of the California Education Code provides the following guidelines for enrichment

students: The governing board of any school district may determine which students would benefit from advanced scholastic or

vocational work. The intent of this section is to provide educational enrichment opportunities for a limited number of eligible pupils,

rather than to reduce current course requirements for elementary and secondary schools.

This program is designed for K-12 students, seeking

advanced scholastic

Cerritos College definition of

courses.

“advanced scholastic

1. Courses meeting Cerritos requirements for an Associate in Arts Degree, excluding remedial English and math courses.

” is…

2. Courses that are transferable to a four-year institution.

Examples of advanced scholastic courses:

3. Vocational courses below 100 level may be taken.

English 100, Math 140, Soc 101, etc.

Examples of vocational courses: Auto 73, Cos 50, Weld 52, etc.

Limitations and Conditions of Enrollment

1. Students shall receive college credit for the community college courses that they successfully complete.

2. Students may

not enroll in pre-collegiate courses (1-99) or physical education courses.* Cerritos College has determined

that non-transferable and physical education courses are the types of courses that would not be considered

“advanced

scholastic”

Example:

in nature.

English 20, Math 20, PE 100, etc.

3. Students may only enroll in courses

not available

4. Assessment testing is an admissions requirement for all Special Admit/College Bridge students regardless of the college

coursework the student wishes to enroll in.

to the student within their school district.

5. Students may not enroll in a college course to alleviate a high school deficiency. For instance, students who failed a course

in high school may not retake it at Cerritos College.

6. Special Admit and College Bridge students

do not

7. Students that have previously enrolled and dropped their courses and/or have received substandard grades and/or have

not made satisfactory progress will not be allowed to continue in neither the College Bridge nor Special Admit programs.

receive priority enrollment status.

*Alternate option for physical education courses only

: Auditing a course is the only other option for a student to take a physical

education course. Auditing allows the student to participate, but he/she will not receive college credit. Audit fees are not covered

by the Special Admit or College Bridge Program. All K-12 students who wish to audit a course must complete the Special Admit or

College Bridge forms.

Cerritos Community College District assumes no responsibility for the supervision of minor students outside of the classroom setting.

Parents/Guardians are responsible for ensuring that their children are appropriately supervised before, after class, and if or when a

class is cancelled or dismissed at an early time. Attendance is required, but not monitored as it is in the K-12 system. Cerritos College

will not call a parent/guardian if a student is absent, nor will we verify attendance.

Additional Parental & Student Information:

Students are expected to comply with all policies and procedures of Cerritos College and Admissions, Records and Services. For

instance, a student must meet all deadlines, which are noted in the class schedule.

Important Notice: Students who do not abide to the school policies will be dropped without notice. To illustrate, a student enrolled

in a non-vocational course below 100 will be removed from the course.

Eligibility Requirements

Special Admit (K-10

Grade) College Bridge (11

& 12

Grade)

New Special Admit students must take assessment tests New

College Bridge students must take assessment tests

New and Continuing Special Admit Students

New and Continuing College Bridge Students

a) G.P.A. - 2.5

Max Units: 4 units each Fall, Spring, and Summer

a) G.P.A. - 2.0

Max Units: Spring & Fall 8 units, Summer 7 units

Signatures Required from Each Listed c)

Signatures Required from Each Listed

•

School Counselor/Principal

•

Parent/Guardian

•

School Counselor/Principal

•

Parent/Guardian

•

Student

•

Student

•

Cerritos College Instructor

•

Dean of Admissions, Records & Services

Updated DB: 3/26/10

College Bridge/Special Admit - To Do List

Reminder: Students found enrolled in courses level 1-99 or without proper approval from the Dean will be

automatically

dropped WITHOUT notice.

Please Note: Due to the extra application requirements for Special Admit/College Bridge students, it is strongly

recommended that students complete all of the steps listed on this page prior to their enrollment period. California

State law requires that Special Admit/College Bridge students receive a lower enrollment priority than regular college

students. While Cerritos College cannot guarantee space for Special Admit/College Bridge students, the earlier the

student completes the application process the greater their chances will be to enroll in eligible coursework at Cerritos

College.

Take the Assessment Tests

- Bring a photo ID and your Cerritos College student number.

-Assessment testing is an admissions requirement

for College Bridge & Special Admit students regardless of the

college coursework that the student wishes to enroll in.

-To view assessment test dates go to http://www.cerritos.edu/career-services/assessment-testing/

Please call (562)

860-2451, ext. 2599 for scheduling information.

Complete the Special Admit/College Bridge form. Make sure you have all of the following:

Indicate the course(s) you are planning on enrolling. You may not enroll in pre-collegiate courses or (1-99 level)

or physical education courses. Vocational courses below 100 level may be taken.

1) Examples of vocational courses: Auto 73, Cos 50, Weld 52, etc.

2) Courses with pre-requisites - Students must place into

courses they wish to enroll.

3) High school credit may not be used for college prerequisite clearance (some exceptions may apply).

Have your school principal or authorized counselor sign and complete appropriate sections(s).

Including cumulative G.P.A

Both your parent’s signature and your signature are required.

Complete the Cerritos College Application either in-person or online at: www.cerritos.edu.

- Online applications: Your Cerritos College student number will be emailed to you within 24-48 hours.

- In-Person applications: The Special Admit/College Bridge form must be fully completed & submitted concurrently

with an application.

Submit your: Assessment Test Scores, Special Admit/College Bridge form, & Treatment of a Minor Form

to the Office of Admissions, Records, and Services.

-Check your (my.cerritos.edu) portal for registration appointment and enroll for courses.

To Log in: User Id: Use Student ID Password: Date of Birth (MMDDYY)

Pay Your Fees: online via MyCerritos or in-person

Fees

Enrollment Fee*

Out of State Tuition Fee**

Student Activity Fee

Health Services Fee

Parking Fee* (Optional)

Lab Fees

Subject to legislative change

** Out of state tuition fee is applicable to only students who cannot establish legal residency within the state of

California.

Fall/Spring

Waived

221.00 Per Unit

10.00

16.00

30.00

Vary

Summer

Waived

221.00 Per Unit

4.00

13.00

20.00

Vary

Updated DB: 3/26/10

I:\WP\CCC\80-Pupils\Authorization to 3

Party Consent of Minor NFH 041309.doc

AUTHORIZATION FOR CERRITOS COLLEGE STUDENT

HEALTH SERVICES TO CONSENT TO

TREATMENT OF MINOR LACKING CAPACITY TO CONSENT

I am the

parent

guardian

other person having legal custody ______________________________________

(describe legal relationship)

of ___________________________________________________________________, a minor.

(name of minor)

Date of birth: ____________________________ Student I.D. No.: _____________________

I/We hereby authorize Cerritos College Student Health Services to act as my/our agent to

consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and

hospital care which is recommended by, and to be rendered under the general or special

supervision of, any licensed physician or surgeon, whether such diagnosis or treatment is

rendered at the Student Health Services facility or at a hospital.

I/We understand that this authorization is given in advance of any specific diagnosis, treatment,

or hospital care being required, but is given to provide authority to the above-named agent to

give consent to any and all such diagnosis, treatment, or hospital care which a licensed physician

recommends.

This authorization is given pursuant to the provisions of Family Code section 6910.

I/We authorize any hospital providing treatment to the above-named minor pursuant to the

provisions of Family Code section 6910 to surrender physical custody of the minor to the above-

named agent upon the completion of treatment. This authorization is given pursuant to Health

and Safety Code section 1283.

These authorizations shall remain effective for one year from the date signed below, unless

sooner revoked in writing delivered to the agent named above.

Date: _______________________________ Time: _____________________________

Signature: ____________________________________________________________________

(circle relationship: parent/legal guardian/person having legal custody)

Signature: ____________________________________________________________________

(circle relationship: parent/legal guardian/person having legal custody)

(please fill out form on reverse of this page)

MEDICALLY RELEVANT INFORMATION

Minor’s name: ________________________________________________________________

Minor’s birthdate: ______________________________________________________________

Allergies to drugs, food, insect stings or bites: ________________________________________

______________________________________________________________________________

Medical conditions for which minor is currently being treated: ___________________________

______________________________________________________________________________

Current medications and dosage: __________________________________________________

______________________________________________________________________________

Restrictions on activities: ________________________________________________________

______________________________________________________________________________

Special dietary needs: ___________________________________________________________

______________________________________________________________________________

Primary care physician: Name: ___________________________________________________

Address: _________________________________________________

Telephone number: ________________________________________

Insurance Company: ____________________________________________________________

ID number: _______________________________________________

Group number: ____________________________________________

Mother’s name: ________________________________________________________________

Mother’s address: ______________________________________________________________

Mother’s telephone numbers: Work ___________ Home: ___________ Other ____________

Father’s name: ________________________________________________________________

Father’s address: ______________________________________________________________

Father’s telephone numbers: Work ___________ Home: ___________ Other ____________

Updated DB: 3/26/10

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