5885 Haven Avenue, Rancho Cucamonga, CA 91737-3002 admissions@chaffey.edu (909) 652-6600
Rev 06/2020
Semester and Year (Ex: Fall 2020) ___________________
Student’s Name: _______________________________________________________________________________
Last First Middle Initial
Student’s Address: _______________________________________________ Chaffey ID: __________________
City/State/Zip: ___________________________________________________ Phone: _____________________
High School: ____________________________________________________ Grade Level: _________________
My counselor and I have selected the degree-applicable courses above. I understand that I may not enroll in more
than 11 units in any Fall and Spring term, and 6 units in Summer. I also understand it is my responsibility to pay for
all applicable fees associated with my courses at the time I register, or I may be dropped from my course(s). I will
attend the first day of instruction and will continue to attend all courses for which I am registered. HIGH SCHOOL
PARTNERSHIP: It is my responsibility to share my schedule with my parent and high school counselor and update
them with any changes I make to my schedule. I authorize Chaffey College to enroll me in class(es) on my behalf and
to provide my grade(s) and transcripts to my high school.
_____________________________________________________________ _________________________
Student Signature Date
Print Student Name
Parent Consent: I give my consent for ___________________________________ to be enrolled at Chaffey College
as a special part-time student. I understand that my son/daughter is being considered for admission as a college
student and will abide by all college rules, regulations, and deadlines. I understand that costs for community college
courses are the responsibility of the student. I understand that under FERPA, Chaffey College will not release any
student records other than directory information to anyone, including the parent(s), without the written consent of the
_____________________________________________________________ __________________________
Parent/Guardian Signature Date
Print Parent/Guardian Name
As Principal or Authorized Designee, I recommend this student be permitted to take the college level degree
applicable courses indicated above.
______________________________________________________________ __________________________
High School Principal/Authorized Designee Date
OMNITRANS We offer the Omnitrans Go-Smart Program, which enables you to ride any of Omnitrans’ fixed route
buses with your Chaffey College Student ID Card for a per-semester fee of $8 for a part-time student. Please check
the box below if you wish to opt-in to pay the fee and use this service. Payment must be received to be eligible. (High
School Partnership only; students taking classes on a Chaffey campus are required to pay the Transportation fee).
I wish to participate in the Omnitrans Go-Smart Program through Chaffey College. I understand there is an
additional fee of $8 for part-time enrollment, and that I must remain actively enrolled in order to use this service.
Student Signature _________________________________________ Date ___________________
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Rev. 06/2020
Hereinafter called the “Activity”, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive,
discharge, and covenant not to sue the Chaffey Community College District, its officers, employees, and agents from
liability from any and all claims including the negligence of the Chaffey Community College District, its officers,
employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising
from, but not limited to, participation in the High School Partnership/Dual Enrollment Program (the Activity).
Assumption of Risks: Participation in the Activity carries with it certain inherent risks that cannot be eliminated
regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range
from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint
or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD CHAFFEY COMMUNITY COLLEGE
DISTRICT HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities,
including attorney’s fees brought as a result of my involvement in the Activity and to reimburse them for any such
expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement
is intended to be as broad and inclusive as is permitted by the law of the State of California including Education Code
Section 72640 and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue
in full legal force and effect.
Acknowledgment of Understanding: I have read all previous paragraphs, including the waiver of liability, assumption
of risk, and indemnity agreement, know, fully understand its terms, acknowledge these and other risks that are inherent
to the Activity, and understand that I am giving up substantial rights, including my right to sue. I acknowledge
my participation is voluntary, that I knowingly assume all such risks, ant that I am signing the agreement freely and
voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the extent
allowed by law.
In the event of any illness or injury, I give full authority to the district staff to obtain such medical treatment and/or
surgery from a licensed physician/surgeon, paramedic or hospital as deemed necessary for the welfare of my child. I
acknowledge that I fully and completely understand the potential risks that may be associated with this Activity and that
my child’s participation is strictly voluntary.
Additional Information - Supervision of Minors: Chaffey College assumes no responsibility for the supervision of
minor students outside the classroom setting. Parents are responsible for providing transportation and ensuring their
children are supervised before and after class, and if or when a class is cancelled or dismissed earlier than the
scheduled time. Chaffey College will not call the parent/guardian if a student is absent, nor will we verify attendance.
Course Content College is an adult environment with minimal supervision. Discussion topics and course materials
are generally designed for adult students and may not be appropriate for younger students. Course content will not be
altered to accommodate younger students.
Internet Usage - Many courses required computer lab work or research projects that could involve the Internet.
Chaffey’s computer network provides access to the Internet in classrooms, labs, and the library. The College does not
block access to specific Internet sites. As a result, it is possible for your son/daughter to reach an Internet site that you
may feel contains inappropriate material.
My signature below accepts the terms and acknowledges the information outlined above. My son/daughter has
my approval to enroll in Chaffey College courses.
___________________________________________________________ ____________________________
Student Signature Date Participant’s Date of Birth (m/d/yy)
___________________________________________________________ (______)_____________________
Signature of Parent/Legal Guardian Date Day Phone
___________________________________________________________ (______)_____________________
Print Parent/Legal Guardian Name Night Phone
Name of Health Insurance Company Policy/Group Number
Medical Problems (check one) ____ None ____Yes, Please Explain _____________________________________
Emergency Contact: In the event of accident or sudden illness, Chaffey College will attempt to contact the parents
at the phone number(s) listed above. Please list a designated contact in case we are unable to reach you.
_______________________________________________________ (______)_____________________
Name Relationship Phone
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