Online Consortium Course Approval Form
Instructions: Approval to take an online consortium course during the fall or spring semesters is
needed prior to requesting registration for an online consortium course. This form is also needed to
request approval to take a summer or winter consortium course that has not been pre-approved by
Clarke University. All students may request to register for summer or winter pre-approved consortium
courses without completing this approval form.
____________________________ _____________________________ ____________________
Last name First name Date
Student Level:
Undergraduate: F (0-29 credits) S (30-59 credits). Jr (60-89 credits) Sr (90 + credits)
Graduate: Master’s Doctoral
Select
Term of Consortium Course Enrollment: Fall Spring Summer Winterim
Seeking Consortium Equivalent to the Following Clarke Course
_______________ _________ _________________________
Major Minor Compass Curriculum
Department Course # Course Title
Seeking Consortium Course to Fulfill Elective ______________________________________________________
List Desired Subjects
Reason for request:
_____ I am a senior and need the course to graduate.
_____ I transferred to Clarke and need this major course to progress in my academic program.
_____ The course is needed to remain in a course sequence within my academic program.
_____ I need this course to maintain full time status. Explain: _________________________________________
_____ There are special circumstances warranting this request. Explain: _____________________________
Select Term of Consortium Course Enrollment: FA SP SU CIC Course Prefix/#:_____________
CIC Course Title: ___________________________________ Teaching Institution: ______________________________
Student
Acknowledgement
By signing this form, I (the student), acknowledge that I understand that I will pay an additional fee for
this consortium course, regardless of whether I am already enrolled full-time. For undergraduates, the
cost per credit for taking an online course through CIC is equivalent to the per credit undergraduate
summer rate. For graduate students, the cost per credit for taking an online course through CIC is
equivalent to the per credit graduate rate.
__________________________________________ __________
Student Signature Date
Approvals
Granted Denied _____________________________ ________________________________ __________
Academic Advisor Name Signature Date
Granted Denied _____________________________ ________________________________ __________
Department Chair Name Signature Date
Granted Denied _____________________________ ________________________________ __________
Academic Dean Name Signature Date
The Academic Deans are located in Haas 205 or 206. Please submit this form to the
Registrar’s Office at registrar@clarke.edu or 201 Haas Administration.
