Fillable Fall 2020 Recommendation for Concurrent Enrollment Program (Chabot College)

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Fall 2020 Recommendation for Concurrent Enrollment Program (Chabot College)

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  • 9 check-boxes
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In accordance with the Governing Policy Number 5124 and policies of this District, the following named student is recommended for concurrent enrollment at Chabot College.
Fall 2020 Recommendation for Concurrent Enrollment Program
Office of Admissions and Records ● 25555 Hesperian Blvd. Hayward, CA 94545 ● concurrent@chabotcollege.edu
CONCURRENT ENROLLMENT PROGRAM IS FOR HIGH SCHOOL STUDENTS IN THE 10
TH
,11
TH
AND 12
TH
GRADES.
Before submitting this form, you must complete a current online admission application. Please attach your current high school transcripts and parent
release.
DEADLINE TO SUBMIT: August 3, 2020. Please allow 72 hours for processing.
SECTION 1: STUDENT INFORMATION
(TO BE COMPLETED BY STUDENT)
Name of School:
School Address:
Last Name First Name Middle
Street Address
City, State, Zip
( ) / /
Phone Number Date of Birth Chabot Student ID Number
Email (registration notification will be sent here)
Application Confirmation Number
Current Grade level:
By signing this form
• I have completed the online application for the Spring 2020 semester.
• I am in the 10
th
, 11
th
or 12
th
grade.
• I acknowledge that I will be earning college credit for courses
completed at Chabot College.
• I will abide by the policies and enrollment conditions of the
Concurrent Enrollment Program.
• I understand I will be dropped from courses not listed on my
recommendation.
• I understand that after completion and approval of this form, I need to
register for the approved class(es) online via CLASS-Web.
• I understand that courses listed on this recommendation are for
Chabot College only.
Student Signature
REQUESTED COURSES
COURSE TITLE & NUMBER
(For example: ENGL 1A)
UNITS
(3.0)
PREREQUISITES*
1.
2.
ALTERNATE 1.
ALTERNATE 2.
COURSE RESTRICTIONS:
• Concurrent Enrollment is limited to a maximum of 2 courses or 6 units.
• Enrollment in physical education (P.E.) and basic skills courses (ENGL 100 level, all
ESL courses, MATH 100 level) are not allowed. (Ed. Code 48800)
• Per Chabot English Department policy, student must be at least 16 years old or in
junior standing to take English courses.
• *Many courses require the completion of prerequisite courses
taken at Chabot College or their equivalent at another
institution. Consult the course description in the class schedule
or college catalog for identification of prerequisites. (Title 5,
Sec.55500)
• Placement must be completed prior to registration for English,
Chemistry, and Math courses. Please check Assessment website
(http://www.chabotcollege.edu/Counseling/assessment/)
for
schedule.
• As per Ed. Code 48800, the high school principal or designee of the school, certifies by signing this form that no more than 5 percent of the
total number of students per grade level shall be recommended for Concurrent Enrollment at Chabot College.
• I certify that the above recommended # of units are based on the student’s ability to benefit from “advanced scholastic or
vocational work.”
• I certify that I am the School Principal / Designee, and authorized to sign this form.
AUTHORIZED SCHOOL OFFICIALS (Signatures are required every term. Initials or rubber stamps NOT acceptable.)
Principal or Designee (Print Name)
Principal or Designee (Signature) Date
Date
APPROVED
DISAPPROVED Director of Admissions & Records
Date
Admissions & Records Staff
HSCH
FOR OFFICE USE ONLY
SECTION 2: SCHOOL PRINCIPAL or DESIGNEE
(TO BE COMPLETED BY SCHOOL PRINCIPAL or DESIGNEE)
click to sign
signature
click to edit
Chabot College
Office of Admissions & Records, Bldg.700
25555 Hesperian Boulevard • Hayward, California 94545
Student’s Name: Chabot Student ID #:
SECTION 3: PARENT or GUARDIAN Authorization for Minors
Parent / Guardian (Print Name):
Relationship to minor student:
Parent / Guardian phone:
By signing this form
•
I acknowledge my child’s participation in Chabot College’s Concurrent Enrollment Program.
•
I certify that the school Principal or Designee named above is my child’s school / district authorized representative.
•
I hereby give permission to release my child’s high school transcript to Chabot College.
•
I hereby give permission to my minor child to use the services provided at the Student Health Center.
(NOTE: The Student Health Center providers are bound by confidentiality even though they are treating minors)
•
As the parent / guardian, do you know of any medical problems we should be aware of for this student?
Yes. List medical problem(s) (E.g. heart disease, allergies, mental health, etc.):
No
Parent / Guardian (Signature) Date
NOTE: In case of an emergency, the above parent/guardian will be contacted.
SECTION 4: Release of Personal Information
Attention Student: The Family Rights and Privacy Act require that most information about your attendance, grades, and behavior
at the college cannot be provided to anyone without your written consent. By signing this form, you are giving Chabot College
permission to release information about you to your parent or guardian.
I do not authorize the release and or review of any and all personal information on record, my student records and any
behavior/disciplinary status.
I authorize the release of the following information to my parent(s) or guardian named below:
Any and all personal information on record
Grades and attendance information only
Behavior/Disciplinary status only
Parent(s) or Guardian name(s):
(Print name)
.
Student’s Signature: Date:
Admissions & Records Office
Building 700, First Floor
25555 Hesperian Blvd.
Hayward, CA 94545
Admissions & Records Office
Building 1600, Second Floor
3000 Campus Hill Drive
Livermore, CA 94551
This form is to be used in the event that you have applied to Las Positas or Chabot College for the purpose of enrolling
under the Concurrent Enrollment program and were coded as a non-resident of California.
To be eligible for this exemption, you must meet all of the following:
♦ Completed all steps and documentation as required under the respective college’s Concurrent Enrollment program
♦ Approved/admitted under the respective college’s Concurrent Enrollment program
♦ You are a U.S. citizen, permanent resident, DACA grantee, or alien without lawful immigration status
(undocumented)
INSTRUCTIONS: To qualify for this exemption, fill out the required fields below and bring this form to the Admissions &
Records Office of the college that you most recently applied to and/or is currently indicated as your Home Campus.
W
Last Name, First Name, Middle Initial
Student ID #
I am requesting an exemption of non-resident status at the following institution (PICK ONE):
□ Chabot College
□ Las Positas College
Check one box only that applies to you:
□ U.S. Citizen, Permanent Resident (green card holder), (DACA) Deferred Action for Childhood Arrival grantee, or an
Alien without lawful immigration status (undocumented) (Eligible for exemption)
□ Nonimmigrant alien as defined by federal law (nonimmigrant aliens have been admitted to the United States
temporarily and include, but are not limited to, foreign students holding F visas and exchange visitors holding J visas
(Not eligible for exemption)
By signing below, I certify that the information provided on this form is truthful and accurate and that I meet all
requirements listed on this form.
Student Signature
Date
IMPORTANT NOTICE
AB 2364 allows community colleges to exempt special part-time students, other than nonimmigrant aliens, as defined,
from paying all or parts of the non-resident tuition fee if that student is admitted under the Concurrent Enrollment
program.
□ HSNR
□ Student attributed
□ Student notified
Done by:
Date:
Term/Yr:
A&R Administrator or Designee Date
MO rev. 2/19/2020
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Fall 2020 Recommendation for Concurrent Enrollment Program (Chabot College)

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Completed 25 July 2020

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