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Synchronous Program 2020-2021
Klamath Community College
Special Petition for Admission
When to use this form: For any interested high school student who wishes to enroll in any course
sections with available space and meets all course prerequisites. Klamath Community College
(KCC) reserves the right to make all final enrollment and program decisions.
Last Name: First Name: M.I.:
Mailing Address:
Date of Birth: Male: Female:
Name of High School: Personal E-mail Address:
Phone No.: Course Requested:
Brief Description of Student’s Motivation to Enroll:
Ethnicity _____ Hispanic/Latino _____ Not Hispanic/Latino
Race (please check all that apply)
_____ African American/Black _____ American Indian/Alaska Native
_____ Asian _____ Pacific Islander _____ White
Please Initial Each Paragraph and Sign Below
If accepted, I agree to abide by all academic and behavioral expectations of college-level classes
as described in the KCC Student Handbook online at https://www.klamathcc.edu/handbook,
particularly the sections on “Policies and Procedures” and “Student Conduct,” which describe
attendance standards, academic honesty, and classroom behavior.
Grades may impact your high school GPA. Grades earned for dual credit courses are recorded on
your Klamath Community College transcript and are subject to our Standards of Satisfactory
Academic Progress. Please see website for more detail:
I, ______________________________________, authorize Klamath Community College to release
my educational records, upon request, to the persons listed below, for the purpose of keeping
them informed regarding my education at Klamath Community College.
Persons to whom information can be released:
Name: ________________________________ Relationship: _________________________________
Name: _________________________________Relationship: _________________________________
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In compliance with the Family Educational Rights and Privacy Act (FERPA) I hereby
authorize KCC to release information regarding my enrollment and grades to my high
Student Signature: Date:
Parent Signature: Date:
High School Instructor/Counselor Recommendation
Student Services: Date:
The following is excerpted from number 6 of the KCC procedure titled “Under Age 18 Admissions.”
This procedure applies to students who are under age 18 as of the first day of the term in which a class
UThe student must read and sign below to signify understanding and agreement.
a. The importance of completing coursework in the K-12 system when possible.
b. Rights under the Family Educational Rights and Privacy Act (FERPA).
c. Disclosure that the College is an adult and diverse learning environment, that the College
mandatorily reports suspected abuse of minors, that classes may include known or unknown
sex offenders, that the College will disclose to instructors the fact of a student being under
age 18, and that students may be exposed to graphic material related to violence, sexuality, or
other mature topics.
d. The fact that course content, grades, and activities cannot be altered based on age.
e. That students must follow all College policies, regulations, and conduct codes.
f. Information on services and resources available to all students.
Student Name:
(Print Clearly)
Date: __ ____
Title IX
Klamath Community College is committed to creating a learning and working environment that ensures
equal access and opportunity to education and resources for all of its students, free of bias, discrimination,
and harassment. This includes sexual harassment, domestic and dating violence, sexual assault and
stalking, as well as gender-based discrimination, discrimination against pregnant and parenting students,
gender-based bullying and hazing. We understand that sexual violence can undermine students’ academic
success, and we encourage students who have experienced any form of sexual misconduct or
discrimination to talk to someone about their experience, in order to get the support they need.
If you have experienced or observed sexual violence/assault, harassment, or discrimination of any kind,
reporting options can be found at
Uwww.klamathcc.edu/complaintsU, or you may contact the Director of
Title IX and Student Conduct at 541-880-2364 or UtitleIX@klamathcc.eduU.
24-Hour Crisis Line: students are encouraged to contact the Klamath Crisis Center at 541-884-0390 for
support and assistance 24 hours a day, 7 days a week.
NOTE: Return this form for processing to: Klamath Community College K-12 Support Coordinator, Kelly Kline
7390 South 6
Street, Klamath Falls, OR 97603 Phone: 541-880-2337 Fax: 541-880-2395
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