2019/2020
–
College Credit Plus (CCP)
Teacher and Course Request Form
Complete one form per high school course and submit to Clark State Admissions
–
TLC 118
at
the address below.
HIGH SCHOOL INFORMATION
Is this your first year seeking a College Credit Plus ate?partnership with Clark St
Every College Credit Plus (CCP) partner school is required to designate a high school liaison. This person serves as Clark State’s connection with the
high school regarding all aspects of the CCP program. He/She should be affiliated with the high school, work with students and teachers and able
to be easily reached. This person may need to be contacted during the summer.
Summer Phone:
TEACHER INFORMATION
High school teachers are required to have certain academic credential as prescribed by the Higher Learning Commission (HLC) in order to be
approved as a Volunteer Adjunct Faculty member in Clark State’s CCP program. Teachers may need to be contacted minimally over the summer in
order to ensure their high school class is ready for the upcoming academic year.
Teacher Name:
Current course(s) taught:
Phone:
Summer Phone:
Has this teacher been approved to teach CCP courses for Clark State in previous years?
No*
*If NO – transcripts of all college coursework and a current resume MUST be attached to this request form. Copies are acceptable, please DO NOT fax transcripts.
COURSE INFORMATION
After the high school teacher has been approved as a Volunteer Adjunct Faculty in the CCP program, the college will submit a copy of the course
syllabus to the school district that is entered in the “Proposed Course” section of this form below. The high school teacher must provide Clark State
with a copy of the high school syllabus that will be used in the classroom. Once received, content of the high school syllabus and textbook must be
reviewed by a designated Clark State faculty member to ensure Clark State course equivalency.
High School Course Title(s):
# of sections: Class Length: Full Year Half Year Class Size:
CCP COURSE STATUS:
Requesting Course Reinstatement
(Course has been approved previously for CCP, the teacher and content have not changed.)
Please submit the course syllabus, including textbook information, with this form.
This is a brand new course for CCP
Please consult Clark State’s course descriptions in the current catalog at www.clarkstate.edu and list your proposed Clark State
Community College equivalency course(s) below. Please submit the course syllabus, including textbook information, with this form.
Office Use Only
Course Request Deadline Met? Yes No
Clark State Faculty Name:
Clark State Course Equivalencies:
Clark State Community College | 570 East Leffel Lane | PO Box 570 | Springfield, OH 45501 | www.clarkstate.edu
