Fillable Form 1.: THREE STEP ENROLLMENT PROCESS STUDENT INFORMATION

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Form 1.: THREE STEP ENROLLMENT PROCESS STUDENT INFORMATION

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CONCURRENT ENROLLMENT
SUPPLEMENTAL APPLICATION
UCSC SILICON VALLEY EXTENSION
3175 Bowers Ave, Santa Clara, CA 95054
(408) 861-3700 FAX: (408) 342-0164
opencampus@ucsc.edu
Copyright © 2017 The Regents of the University of California. All Rights Reserved.
7/8/2019
Office Use Only:
○ Approved
○ Denied
I am a current or former UCSC student without a bachelor’s degree. I am applying to Concurrent Enrollment to
complete credits of course work required for my undergraduate degree from UCSC. I acknowledge and give
permission to have my transcript sent to the UCSC Office of the Registrar.
THREE STEP ENROLLMENT PROCESS
1.
Pay application fee by registering for section UCSC.X1000 at https://www.ucsc-
extension.edu/resources/concurrent-enrollment/
2.
Submit Concurrent Enrollment Supplemental Application Form
3.
Submit Instructor Approval Form
Processing delays caused by failure to provide information requested may result in the denial of the application.
STUDENT INFORMATION
Today’s Date:
Applying for: ○ Fall ○ Winter ○ Spring Year:
Name
Last First Middle
Mailing Address
Street City State Zip
Phone Number Email Address
If you have one, please list your Cruz ID (username@ucsc.edu): ________________________________________________
Please answer each question as it applies to you. if you have been a UCSC student, the information will be verified through the appropriate
campus office(s). Failure to report or explain circumstances may be grounds for denial of Concurrent enrollment.
○ Yes ○ No Have you used or plan to use disability-related accommodations?
___________________________________________________________________________________________________
Note: Please visit the Disabilities Resource Center or call 831-459-2098 if you need accommodations.
○ Yes ○ No Have you ever been dismissed, suspended or placed on warning or probation, either academic or
disciplinary, by any institution, including UCSC? If yes, explain the circumstances:
Note: If you are currently barred or dismissed from UCSC, you are not eligible for Concurrent Enrollment.
○ Yes ○ No Do you have any financial obligations to UC (including library fines or lab fees or any loans that are
not yet in repayment status)? If yes, please explain the circumstances:
Note: Outstanding debts to the campus must be cleared prior to Concurrent Enrollment. This information will be verified by checking campus records.
○ Yes ○ No Have you ever been barred from the campus by police or court order?
Student Statement: I certify that I have considered all questions carefully and that my statements are true and
complete to the best of my knowledge.
Name Signature Date
CONCURRENT ENROLLMENT
SUPPLEMENTAL APPLICATION
UCSC SILICON VALLEY EXTENSION
3175 Bowers Ave, Santa Clara, CA 95054
(408) 861-3700 FAX: (408) 342-0164
opencampus@ucsc.edu
Copyright © 2017 The Regents of the University of California. All Rights Reserved.
7/8/2019
Office Use Only:
○ Approved
○ Denied
Date
Signature
Phone
Parent/Guardian Statement: The student named on this application has my approval and support to enroll in and pursue
university level course work through Concurrent enrollment.
Date
Signature
Phone
Title
School
☐
I am a current high school student.
(You must obtain signatures from your high school counselor and your parent/guardian indicating your ability to pursue
university level work.)
COUNSELOR STATEMENT:
it is my belief that the student named on this application has the appropri
ate preparation and
ability to pursue university level work.
If you are a minor under the age of 18 years old, please include the following page with your application:
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Form 1.: THREE STEP ENROLLMENT PROCESS STUDENT INFORMATION

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Completed 16 March 2022

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