Fillable Independent Study Request Form (Adirondack Community College)

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Independent Study Request Form (Adirondack Community College)

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Office of Records and Registration
640 Bay Road, Queensbury, NY 12804-1445
CALL: 518.743.2279 | FAX: 518.832.7601 | EMAIL: registrar@sunyacc.edu
Page 1 of 3 Updated: 4/2/2020
Independent Study Request Form
Independent Study Course Guidelines
SUNY Adirondack recognizes that additional learning experiences above and beyond those offered on the semester’s class schedule
are at times appropriate to assist a student with pursuing his or her educational goals and objectives. Independent study courses can
take many forms including those described below.
A course which the College offers but which is not being taught during the needed semester or time frame. Credit granted
would be recorded the same as if the course was taken in the traditional learning environment. The course number is also the
same as if offered in a classroom or lab.
A course or project not included in the College Catalog which would enhance the student’s educational experiences and allow
the student the opportunity to pursue topics in depth. In such cases a course outline must be developed and appropriate credit
assigned. The course number assignment will be 299; the three-letter alpha prefix will indicate the discipline. The course title
will be the name of the independent study project.
All independent study requests must be approved by the responsible instructor as well as the Division Chair and Associate Vice
President for Academic Affairs.
Request Form Instructions
Any matriculated student who wants to do an independent study must initiate a conversation with an instructor to request the
independent study. The student must then complete the student information section and sign.
Instructor must complete the course information and justification sections and sign.
Independent study instructors must clearly describe the project scope and outcomes as accurately as possible.
A syllabus or outline should be attached or on file with the Division office.
If this is a course not included in the College Catalog, an attached course outline and/or syllabus will be the documentation for
transfer institutions, if requested.
The assignment of credit hours must be consistent with the required amount of student activity. Refer to the Assignment of
Credits Hours Rubric in N:\Academics\Curriculum\Assignment of Credit Hours Rubric.pdf.
Once signed by the instructor, the form is forwarded to the Division Chair and Associate Vice President for Academic Affairs for
approval. Students and faculty are urged to keep a copy of the application.
Registration Information
Once the request form has been completed, the Office of Academic Affairs will send the completed form to the Registrar’s office for
processing. The Registrar’s office will then work to create the course and register the student. Students are encouraged to check their
registration status in Banner; no other confirmation of registration will be sent unless the registration affects the student’s bill.
Please note independent study courses are charged at the same rate as other coursework. The course will be subject to any fees which
would be required in a traditional classroom or lab setting.
The deadlines governing registration, payment, state aid certification, and grades are the same for independent study courses as for
regularly scheduled courses.
Office of Records and Registration
640 Bay Road, Queensbury, NY 12804-1445
CALL: 518.743.2279 | FAX: 518.832.7601 | EMAIL: registrar@sunyacc.edu
Page 2 of 3 Updated: 4/2/2020
Independent Study Request Form
The student and instructor must complete the following information. Once complete and all signatures have been completed, the form should
be submitted to the Associate Vice President of Academic Affairs for review. If the request is approved, the form will be forwarded to the
Registrar for processing.
Student Information
Student Name (Please print): _________________________________________________ Banner ID: ______________________
Declared Primary Major: ___________________________ Concentration (if applicable): ____________________
Declared Secondary Major (if applicable): ________________________ Concentration (if applicable): ____________________
Cumulative GPA: _____________ Number of Earned Credits: ________
Statement of Financial Responsibility and Registration Verification
By registering for classes at SUNY Adirondack, I acknowledge and agree that I am financially responsible for all charges related to my
registration and housing.
I understand that if financial payment and/or arrangements have not been made by the due date, the College reserves the right to remove
me as a student for non-payment, deny me access to my registered classes, and/or place a "hold" on my student records restricting me
from registering, graduating, and/or obtaining a transcript until the account is paid in full. I am responsible for all late charges incurred.
Failure to attend classes does not absolve me from financial liability. In all cases it is my responsibility to drop classes by the published
drop/add date(s) and I accept financial liability for these classes in accordance with the SUNY Adirondack Bill Adjustment/Liability
Schedule. SUNY Adirondack may call (personally or automated) or text any phone number that I have provided to the College and leave
a message regarding any outstanding account I have. I understand that, if the College texts me, I will be able to opt out. The College may
use a collection agency or take legal action for any account balance due and I will be responsible for all charges owed which may include
collection and/or litigation costs or attorney fees.
I understand that the College will (1) electronically post my 1098-T form (Tuition Statement) to my Banner account so I can download the
form for tax purposes and (2) mail a paper copy of my 1098-T to my primary address on file. I understand that I am responsible for providing
the College with updated contact information either through Banner or in person at the Registrar's Office in Warren Hall or at SUNY
Adirondack Saratoga.
Federal and State Financial Aid Acknowledgement and Permission Statement: I understand that financial aid (state and federal)
is only available to matriculated students. A matriculated student is a student who has been accepted to the College and is pursuing a
SUNY Adirondack degree. If I am a matriculated student who is eligible for financial aid and my financial aid is reduced or canceled for
any reason, I am responsible for all charges on my account. I give SUNY Adirondack permission to use any federal student aid (Pell Grant,
SEOG, Direct Loan) to pay any current charges that I incur for educational related activities and any other charges (institutional and non-
institutional) related to my attendance. I understand that at any time I may contact the Student Accounts (Bursar) Office to revoke this
permission regarding the use of my federal student aid.
My signature below indicates that I am in agreement with and/or acknowledge the statements above. Acceptance and acknowledgement
of this Financial Responsibility Agreement is required in order to process your course registration.
Student Signature: Date:
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Office of Records and Registration
640 Bay Road, Queensbury, NY 12804-1445
CALL: 518.743.2279 | FAX: 518.832.7601 | EMAIL: registrar@sunyacc.edu
Page 3 of 3 Updated: 4/2/2020
Course Information
Semester: ❑ Summer ❑ Fall ❑ Winter ❑ Spring Year: ________ Number of Registered Credits for Requested Semester: ______
Part of Term for course: ❑ Full Term ❑ First Half ❑ Second Half ❑ Ten Weeks ❑ Other: ____________
Course Subject and Number (299 if not in the catalog): ______________ Course Title: _________________________________
Credit Hours: __________________ (Refer to N:\Academics\Curriculum\Assignment of Credit Hours Rubric.pdf)
Course Outline: ❑ The outline is attached to this request ❑ The outline is on file with the Division Office
Independent Study Justification
1. The student anticipates graduating at the end of the requested semester and the course is needed for graduation. ❑ Yes ❑ No
a. If no, the course is needed for the student to stay on track. ❑ Yes ❑ No
2. The course cannot be taken during the requested semester. ❑ Yes ❑ No
a. If yes, why can’t the course be taken; ❑ Cancelled ❑ Scheduling Conflict ❑ Other: _____________________
3. The course cannot be taken during a future semester. ❑ Yes ❑ No
4. There is not an available course substitution to meet the requirement. ❑ Yes ❑ No
Additional information to support request if needed: ___________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Manner in which the course will be completed: ________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Required Signatures (All signatures must be obtained in the order listed. If the form is being completed remotely, approvals
may be received via emails sent via SUNY Adirondack accounts)
Student Signature: Date:
Instructor: Date:
Division Chair: Date:
Associate Vice President for Academic Affairs: Date:
Processing Information
Notes from Associate Vice President (if applicable) _________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
REGISTRAR’S OFFICE: Date Processed: __________ Initials: __________ CRN: ____________
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Independent Study Request Form (Adirondack Community College)

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Completed 20 September 2020

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