Las Positas College
PROBATION CLEARANCE FORM
For ACADEMIC SUCCESS
□ Fall □ Spring □ Summer Semester 20______
Name: ___________________________________________________ W# or SSN _______________________
Last First
Address ____________________________________________________________________________________________________
Street City Zip Code Phone
GENERAL INFORMATION (Student to Complete)
Major _____________________________ □ Certificate □ A.A./A.S. degree □ Transfer to: _________________________________
Number of hours worked each week: ___________________ Number of units enrolled this semester: ________________________
Family responsibilities (e.g. married, children, childcare etc.): ________________________________________________________
Support services that I have used at Las Positas (e.g. tutoring, math lab, DSPS):_________________________________________
My lack of academic success, in my opinion, is due to the following factors:
□ Number of hours I worked Planned Schedule:
□ Did not officially withdraw from a class (and should have) (Hours per week)
□ Too little time to study _____________ Work
□ Did not know how to study properly _____________ Class
□ Need extra help to understand class work _____________ Study
□ I have □ may have a learning disability _____________ Other
□ Lack of support (family does not want to help me attend college)
□ Personal problems make it difficult to study _____________ Total Hrs
□ Lack of motivation
□ Other: ___________________________________________
TO BE COMPLETED WITH A COUNSELOR
Check all that apply:
□ My semester G.P.A. will be: ______________
Academic Status:
□ Limit total units next term to: _____________
□ Reduce work hours per week to: ___________ □
Academic Probation 1
□ Enroll in College Study Skills / Learning Skills/ Library Skills. □ Academic Probation 2
□ Sign-up for Tutoring in Building 2400. □ Progress Probation 1
□ Meet with Counselor ________________ next term. □
Progress Probation 2
□ Apply for Academic Renewal.
□ See instructor: ______________________________
□ Utilize free services from: _______________ (Integrated Learning Center, English lab, Tutorial, etc.)
□ Enroll in: □ Psychology Counseling 15 (Study Skills) □ Psychology Counseling 10 (Career Planning) □ Other: ________
□ Take assessment placement exam in: □ English □ Math □ Chemistry □ Biology □ ESL
□ Referral made to: □ Disabled Student Services □ EOPS □ CalWORKS □ Financial Aid
□ Schedule a meeting with a Counselor early next semester to develop/update a Student Educational Plan (SEP).
□ Complete Most Recent Grade of Record form for: _________________________________________
□ Suggested course(s) to repeat: ___________________________________________________________
□ Other: ______________________________________________________________________________
□ Short Term Educational Plan: Courses approved for next semester. Units
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_____________________________ _________ ______________________ _______
Student Signature Date Counselor Signature Date
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