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KAUAI COMMUNITY COLLEGE (Kauai Community College)

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______________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________________
_____________________________
__________________________ __________
Policy Guideline No. 4-16 Attachment 3
Rev. April 25, 2016
KAUA’I COMMUNITY COLLEGE
Request for PLA Credit by Portfolio Evaluation
Please attach your completed “Is the Portfolio Review Process Right for Me?” assessment to this form.
*Note that students must pay requisite fees and attach receipts to this form for approval to be final.
Name:
____________________
_
___________________
_
_____
UH Number
_____________
Last First MI
Phone:
____________________
UH Email:
_____________________
Major:
_____________
List the courses you are applying for PLA credit.
Course Alpha & Number
Name of Course
Number of Credits
Describe the training, study, and/or experience you have that you would like to get academic credit
for by portfolio
_________________________________________________________________
List the evidence of prior learning can you gather to support your portfolio.
�
Certificates L
etters from supervisors
Transcripts Awards Samples of
work
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Other : please describe
___________________________________________________________
Academic Advisor:
I have provided the PLA policy guidelines KCCP 4-16 to the student.
I have discussed PLA benefits and risks with this student:
Academic Advisor Signature Print Name Date
Faculty:
I have discussed this request with the student and
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________
__________________________
__________
__________
__________
Policy Guideline No. 4-16 Attachment 3
Rev. April 25, 2016
____
agree (fee assessed) _
___
disagree (no fee assessed) to authorize this PLA evaluation.
If agree also, the student has chosen the:
(check one) _
___
_ Mentoring Option
_____
Self-directed Option
If declined, please explain here and initial:
PLA Fee* (60% regular tuition for attempted credits) $_________
*PLA fee is non-refundable even if no credits are awarded
__________________________
__________
Faculty Signature Print Name
_____________________________ __________________________
Student Signature Print Name
If Mentoring Option is selected above:
Division Chair:
Name of the faculty mentor
_________________________
Division Chair Signature
Print Name
Date
Date
Date
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KAUAI COMMUNITY COLLEGE (Kauai Community College)

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Completed 3 February 2021

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