Fillable District Information Concurrent Enrollment Form (Cerritos College)

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District Information Concurrent Enrollment Form (Cerritos College)

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Dear Colleague:
This package includes information regarding Cerritos College policies and procedures for the Special Admit and
College Bridge programs.
This communication contains the following materials:
Authorized Signatures form
must be completed by the School Principal or designated official and submitted to
Cerritos College Admissions and Records office. The form will assist our admissions staff to verify who is
authorized to approve Special Admit/College Bridge forms for your institution. (Must be mailed by school)
The Session Certification form
must be completed by the School Principal and mailed to the Cerritos College
Admissions and Records Office for each Summer Session only. . (Must be mailed by school)
Please refer to California Education Code Section 48800-48802 for further details.
Special Admit /College Bridge form
– Both programs use the same form.
Special Admit/College Bridge Check list
- The checklist is a guide to assist your students through the
admissions process.
Health Services to consent to Treatment of minor lacking capacity to consent
- This form is to obtain vital
medical information, should your student require medical assistance at any time while enrolled in courses
at Cerritos College.
This authorization is given pursuant to the provisions of Family Code section 6910.
Electronic versions of these forms may be found at:
http://cms.cerritos.edu/admissions-and-records/online-forms/forms-online
Please mail your Authorized Signature and Session Certification form to the following:
Sue Boss
Cerritos College
Admissions, Records & Services
11110 Alondra Blvd.
Norwalk, CA 90650
Please verify course availability
prior to referring your students to Cerritos College.
College Bridge/Special Admit students are not given priority enrollment. They may check online beginning
the month of April to view their Summer enrollment appointment.
College Bridge/Special Admit students must complete the application process to be assigned an
enrollment appointment.
Thank you,
Sue Boss Stephanie Murguia
Admissions & Records Technician II Dean of Admissions, Records & Services
sboss@cerritos.edu smurguia@cerritos.edu
Cerritos College Cerritos College
Admissions, Records and Services Admissions, Records and Services
Updated 7/28/2015
N a m e o f I n s t i t u t i o n :
Sue Boss, Admissions, Records, & Services
11110 Alondra Blvd. Norwalk, Ca 90650-6298 (562) 860-2451 Ext: 2118
Please print your name and current position .
Authorized Signature Form
This allows Cerritos College Admissions, Records, & Services to verify signatures from designated counselors and/or administrators
authorized to sign Special Admit and College Bridge forms. Admissions, Records, & Services must receive the Authorized Signature
form prior to any of your students concurrently enrolling at Cerritos College.
Address City Zip
Contact Name* Contact Fax
*All pertinent forms and information will be provided to the contact person only.
This institution is a: Public School Private School Home School Other___________
Principal’s Name Principal’s Signature / Date
Name of Head Counselor Signature / Date
Print Name & Position Signature / Date
Contact Telephone Number Contact Email
Ofce use only:
Date: __________
Initials: __________
Academic Year: _________________
Print Name & Position Signature / Date
Print Name & Position Signature / Date
Updated 7/28/2015
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11110 Alondra Blvd. Norwalk, CA 90650-6298 Admissions & Records (562) 860-2451 ext: 2118
Summer Session Certification
Original Form must be mailed by the school.
I certify, as principal of ______________________________________, that all pupils recommended for
Summer 2016 meet all of the following criteria:
1. Each pupil demonstrates adequate preparation in the discipline to
be studied.
2. Each pupil has exhausted all opportunities to enroll in an
equivalent course at his or her school of attendance.
3. The total number of recommendations complies with the
requirement allowing only 5% of the total number of students
enrolled in the high school’s grade level to be recommended for
admission to Cerritos College.
The total student enrollment for the Summer 2016 academic year.
K-8 Please check here.
9
th
grade _____________ x 5% = ___________
Total # of enrollment
10
th
grade _____________ x 5% = ___________
Total # of enrollment
11
th
grade _____________ x 5% = ___________
Total # of enrollment
12
th
grade _____________ x 5% = ___________
Total # of enrollment
_____________________________________
Principal Name (Please Print)
___________________________________ _______________
Principal Signature Date
Cerritos College
Admissions, Records and Services
Ofce use only:
Date: __________
Initials: __________
Updated 7/28/2015
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Special Admit K-10
th
/College Bridge 11
th
&12
th
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
th
Grade) College Bridge (11
th
& 12
th
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
b) Max Units: 4 units each Fall, S
pring, and Summer
a) G.P.A. - 2.0
b) Max Units:
Spring & Fall 8 units, Summer 7 units
c) 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 7/28/2015
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.
Register for Classes:
-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
220.00 Per Unit
10.00
19.00
40.00
Vary
Summer
Waived
220.00 Per Unit
4.00
16.00
25.00
Vary
Updated 7/28/2015
CERRITOS COLLEGE Special Admit - K-10
th
College Bridge - 11
th
& 12
th
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 Instuon: Public School Private School Home Schooled Other:
Home Phone: 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 ocial
School Ocial: I cerfy that the above-named student is academically qualied for the course (s). The student is :
Currently Aending Not Aending an accredited private or public school and has district approval to enroll in clas-
ses at Cerritos College as long as these do not conict with the school session.
Term: Spring Summer Fall Year: ________
Class # Course Name & No. Units
Cerritos College Instructor’s Signature
Required for K-10
th
Grade Students only
Cumulave GPA
____._____
Special Admit- Spring/Fall /Summer-Max. 4 units* College Bridge – Spring /Fall-Max. 8 units* Summer-Max. 7 units*
*Excepons may be considered. Please see Dean of Admissions, Records and Services – Stephanie Murguia
Summer Session Only: I cerfy, as principal, that all students recommended for Summer _______ (yr.) meet all of the following criteria:
Demonstrates adequate preparaon in the discipline to be studied;
Has exhausted all opportunies 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 cerfy that this student would benet from advanced scholasc or vocaonal coursework listed above.
School of Aendance: Expected Graduaon Date:
Counselor/Principal Signature: Date:
To be completed by parent or guardian
I give my permission for emergency rst 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 specically 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 aending Cerritos College. All college coursework is
governed by the Family Educaon Rights and Privacy Act, which prohibits release of academic informaon. I understand that I will
not have access to my child’s academic records (including, but not limited to grades and transcripts) without his/her wrien con-
sent - regardless of age. I have read and understand the aached informaon.
Parent/ Guardian Signature: Date:
Admissions Sta Use Only:
Engl/Read/Math Tests Unit Limit
Student Group Equaon Variables
Term Acvated Minor’s Health Form
Received Substandard Grade
Principal’s Inials
English : __________ Reading: ___________ Math: __________
Initials : __________________ Date: ___________
Processed by : __________________ Date: ___________
Assesment Scores
Updated 7/28/2015
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)
Term: Spring Summer Fall Year: ________
Updated 7/28/2015
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 7/28/2015
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District Information Concurrent Enrollment Form (Cerritos College)

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Completed 18 July 2020

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