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South Arkansas Community College (South Arkansas Community College)

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Application and Registration Form
Please print legibly in black or blue ink.
South Arkansas Community College
Early College Start
Student Information
School Information
COURSE INFORMATION
CHECKBOX
FALL SOUTHARK COURSE
CHECKBOX
SPRING SOUTHARK COURSE
World History/Civ. To 1700 (HIST 1003)
World History/Civ. Since 1700 (HIST 1013)
U.S. History to 1876 (HIST 2013)
U.S. History since 1876 (HIST 2023)
College Algebra (MATH 1023)
Plane Trigonometry (MATH 1033)
Composition I (ENGL 1113)
Composition II (ENGL 1123)
Literature I (ENGL 2213)
Literature II (ENGL 2223)
Other: Class:_______ Section:_______
Other: Class:_______ Section:_______
Other: Class:_______ Section:_______
Other: Class:_______ Section:_______
Release of Students Records/Permission to Participate
Release of
Signatures
SOUTHARK USE ONLY
Student ID # 777-
FERPA YES NO
Name: ________________________________________
(Last) (First) (MI )
Mailing Address: ________________________________
(Street or P.O. Box)
______________________
________________________
(City) (State) (Zip Code)
Gender: __Male __ Female
Student’s Cell Number: ________________________________
Parent/Guardian’s Preferred Number:______________________
Preferred Email Address: _______________________________
Birthdate:____________ / ____________ / ___________
month date year
Anticipated graduation date: _________ / ____________
month year
Race/Ethnicity:
__ American Indian or Alaska Native __ Asian ___ White
__ Black or AA ___Native Hawaiian or Pacific Islander
Do you consider yourself to be Hispanic/Latino?
__ Yes __ No
Have you taken concurrent classes before? __ Yes __ No
___ El Dorado HS ___ Strong HS
___ Parkers Chapel HS ___ Smackover HS
___ Junction City HS ___ Westside CS
SOUTHARK USE ONLY Test scores Date Taken
ACT E _____ M ______ R _____ ________
Accuplacer R _____ Alg _____ SS_____ ________
Next Gen. R______ QAS ______W____ ________
Pre-requ
isites met: _______________________________
Verified by: _____________________________________
I approve the release of this student’s records, including but not limited to transcripts, test scores and immunization records, to South Arkansas Community
College during and after participation in the ECS program. I also approve the student’s ECS participation. I acknowledge acceptance of the conditions noted
on the REVERSE side of this FORM. I give permission to SouthArk faculty/staff to report grades and other educational records, including student financial
account records, directly to officials at the participating high school. I also understand that under FERPA, a parent may not obtain academic records or
complete SouthArk’s processes for the student without the student’s written permission, even if the student is a minor. I certify that none of the information
requested on this form is false or has been withheld. I understand that withholding information may make the student ineligible for admission and enrollment.
I also understand that the student will not be fully admitted until all required credentials has been submitted and approved and all other stipulated admission
criteria has been met.
_________ _________
Student Signature Date Parent/Guardian Signature Date
Check box if you agree: By participating, you consent to receive SMS/MMS messages. No purchase required. Msg&data rates may apply.
Stud
ent Cell Phone: _____________________________________ Parent/Guardian Cell Phone: ____________________________
*Please note that a FERPA form must be on file for parents/guardians to receive text message communication.
I approve this student to take the course(s) listed above for concurrent credit through South Arkansas Community College.
______ _________
High School Official Title SouthArk Official
The following is information about participation in the SouthArk Community College ECS program:
1. To be eligible for the Early College Start program, you must currently be enrolled in a high school, reside in the
SouthArk service area, and be able to show documentation, if requested, by SouthArk.
2. Participation in the Early College Start Program requires students to abide by all rules and regulations of the college.
This includes submitting ADD/DROP forms if there are changes to your schedule after registration.
3. Students are responsible for the cost of tuition and fees of courses not covered by the Arkansas Concurrent
Challenge Scholarship. Payments must be made to SouthArk according to the college’s course schedule for the
appropriate semester; students will receive account holds and may be dropped for non-payment.
4. If you do not consent for SouthArk to report college records to high school officials, you must submit a letter in writing
to SouthArk’s Advising & Career Services department. In addition, you must provide an official SouthArk transcript
to your high school to transfer grades. Other student information, such as test scores, withdrawals, and attendance
must be reported directly by you as required by your high school if you do not consent.
5. You must meet all academic skills and college course prerequisites applicable to the course(s) for which you enroll.
SouthArk reserves the right to withdraw a student who does not meet requirements.
6. College courses taken while a student is still in high school count toward Federal Student Aid policies; therefore,
failure of concurrent courses could result in a student entering college on academic probation.
7. You own your college academic records. Even if you are a minor, your academic records may not be released to
your parent or guardian without your consent under the Family Educational Rights and Privacy Act (FERPA).
8. The decision to use any SouthArk course for high school graduation requirements rests with the high school, per
the policies of the independent school district.
9. A student’s semester grade reflects only the work prescribed in the SouthArk syllabus for that course. This means
that his or her SouthArk grade may be different from the grade he or she receives on the high school report card if
the instructor/teacher includes units of instruction beyond what is required in the college course or if the student
receives bonus points for extra work not covered in the SouthArk syllabus.
10. SouthA
rk reserves the right to modify its programs, policies, or procedures as needed without prior notice.
Student Checklist
New Students Returning Students
Visit your guidance counselor for concurrent
options and course approval.
Visit your guidance counselor or SouthArk’s
Early College Coordinator for Early College
Start forms.
Complete the “CONCURRENT CREDIT”
application for admission online: southark.edu
Return completed Early College Start (ECS)
form signed by student and parent to SouthArk’s
Early College Coordinator.
An application is not complete until the ECS
form is submitted and the following forms
are sent to SouthArk:
a. An official transcript
b. Test scores (ACT, ACCUPLACER)
c. Immunization records
Optional: Submit the FERPA form to consent
release of your academic records to your
parent/guardian.
Check your e-mail for important information
regarding your registration and SouthArk log-in.
Pay course fee at the SouthArk’s bookstore in
person or via phone: 870-864-7163
Complete the Concurrent Credit Student
Orientation.
To schedule the ACCUPLACER Next Generation,
call SouthArk’s Testing Center at 870.864.7196.
For questions, contact
Alejandra Muñoz
Early College Coordinator
870.864.8416 l earlycollegestart@southark.edu
El Dorado Conference Center 241
Visit your guidance counselor for concurrent
options and course approval.
Visit your guidance counselor or SouthArk’s
Early College Coordinator for Early College
Start forms.
Return completed Early College Start (ECS)
form signed by student and parent to
SouthArk’s Early College Coordinator.
Optional: Submit the FERPA form to consent
release of your academic records to your
parent/guardian
Check your e-mail for important information
regarding your registration and SouthArk log-in.
Pay course fee at the SouthArk’s bookstore in
person or via phone: 870-864-7163
Complete the Concurrent Credit Student
Orientation.
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Completed 2 February 2021

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