Fillable Underage College Application (Chemeketa Community College)

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Underage College Application (Chemeketa Community College)

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Underage College Application
16-17 Years Old
High School Partnerships
Phone: 503.399.5293 Fax: 503.365.4703
Email: highschool@chemeketa.edu 
4071 Winema Place Building 50, Room102
Salem, OR 97305
First Name
Which term will you enroll at Chemeketa Community College? (choose one)
SSN# (optional)
Middle Name
Last Name
Former Last Name
Mailing Address
City
Zip
Daytime Phone Number
Cell Phone Number
Date of Birth
Email Address
High School Name (no abbreviations please)
City
State
Name of last college attended other than Chemeketa
City
State
Underage Admission Application -
(Ages 16-17)
Chemeketa High School Partnerships
4071 Winema Place,
Bldg. 50, Room 102
Salem, OR 97305
Phone: (503) 399.5293
Email: highschool@chemeketa.edu
You will be issued a Chemeketa student identification (ID) number (K#) to be used as your primary ID. If you provide your social security number to the college it will only
be used for record keeping purposes, complying with federal and state requirements, doing research, reporting, extending crediting or collecting debts. You may be
required to provide your SSN to the college for compliance with specific federal and state regulations such as applying for financial aid, loans, grant programs and tax
reporting requirements. Providing your SSN means that you consent to the use of the number in the manner described. Your SSN will not be given to the general public.
Please note that per OAR 559-004-0400, if you choose not to provide your SSN, you will not be denied any rights as a student.
Summer (June) Fall (Sept.) Winter (Jan.) Spring (March) Year: 20
/ /
Ethnicity and Race: What is your ethnicity? Hispanic or Latino Not Hispanic or Latino Gender: Male Female
Select one or more races to indicate what you consider yourself to be:
American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Indicate your high school status: (choose one)
Did not complete high school External diploma program Certificate of Initial Mastery Attendance completion GED year
Alternative high school diploma Still in high school Certificate of Advanced Mastery Proficiency exam High school graduation year
Indicate your college status prior to Chemeketa: (choose one)
Have not attended college Short -term training, private vocational school award, or other
Indicate the main reason you are here this term: (choose one)
Take classes to transfer to 4-year college Explore career or educational options Learn English Learn skill to get a job
Take classes to finish high school or GED Improve writing, reading or math skills Improve job skills Personal enrichment Other
Chemeketa Community College releases only very limited information regarding students: enrollment status, dates of enrollment, degree or certificate,
program of study, athletic statistics or honors awarded. If you do NOT want any person outside of the college, including prospective employers, to
know any of these, you must file a request for Non-Disclosure of Student Information form with the Admissions office.
I certify that all statements on this application are complete and true. I also understand that if I am admitted and do not enroll for the term to which I
am admitted, I will need to reapply for admission. Submitted materials will not be returned nor duplicated.
Student Signature: ____________________________________________________________________
Date: ________________________
Email completed form to highschool@chem eketa.edu OR
Drop off at 4071 Winema Place, Bldg. 50, Salem, OR 97305 (please place in mailbox outside of front door)
The College is an equal opportunity/affirmative action employer and educational institution committed to an environment free of discrimination and harassment. Questions regarding sexual
harassment, gender-based discrimination and sexual misconduct policies or wish to file a complaint contact the Title IX coordinator at 503-584-7323. For questions about equal employment
opportunity and/or affirmative action, contact 503.399.2537. To request this publication in an alternative format, please call 503.399.5192.
Will you have lived in Oregon for the
90 days just prior to the term you
begin?
No
Yes
Do you plan to earn a degree, certificate
or diploma at Chemeketa? (choose one)
Yes, high school diploma
No, here to take classes
Undecided
11/9/2020
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signature
click to edit
☐GED Options (HSP)
☐GED preparation classes
☐GED testing only
☐Specialized Programs
☐High School Completion (Winema High
School)
☐College Credit Courses (Underage College
Credit/Early College/Dual Credit)
☐High School College Transition (HCT)
(Mo/Year)
(Mo/Year)
Underage Approval Form - (Ages
16-17)
Chemeketa High School Partnerships
4071 Winema Place, Bldg. 50, Room 102
Salem, OR 97305
Phone: (503) 399.5293
Email: highschool@chemeketa.edu
College Policy 5110 Procedure 5111 requires that this form be completed by students planning to enroll at Chemeketa Community
College who are under the age of 18 and do not have a high school diploma or GED. Completion of this form is not required for
students enrolling in College Credit Now classes that are offered at local high schools.
Student
Last Name: ______________________________________________ First Name: _______________________________________
Date of Birth (month/day/year): ________________________________________ Age: ___________________________________
Please indicate term in which you would like to enroll: ☐Summer (June) ☐Fall (Sept.) ☐Winter (Jan.) ☐Spring (March) Year: 20
Please indicate the program or classes in which you would like to enroll:
Please indicate specific course you wish to enroll: _____________________________________________________________________________
Parent/Legal Guardian
Print Name: ___________________________________________________________ Home Phone: ____________________________________
Signature: ____________________________________________________________ Date: ___________________________________________
High School or Home School Approval
Referring High School/Home School: _______________________________________________________________________________________
Counselor/Administrator Signature: _________________________________________________________________________________________
Telephone: ___________________________________________________________ Date: ___________________________________________
- - - - - - - - - - - - - - - - - - - - - - - - DO NOT WRITE BELOW THIS LINE - - - - - - - - - - - - - - - - - - - - - - - -
☐ Released from Compulsory Education - Beginning Date: _____________________________________________________________________
☐ Exemption from Compulsory Education for GED (student is released for one year) - Beginning Date: __________________________________
☐ Partial Release - Date: _________________ ☐Summer (June) ☐Fall (Sept.) ☐Winter (Jan.) ☐Spring (March)
☐ Partial Release - Date: _________________
Placement Tests: ☐ Completed - Date: _________________
Approved Course(s):
High School Partnerships Signature (credit and non-credit courses): _______________________________________________________________
Community Education Signature (non-credit community education courses only): _____________________________________________________
☐Non-credit classes
☐Expanded Options (EOP)
☐Community Education classes
11-2020
- AN APPROVAL E-MAIL MAY BE USED IN LIEU OF SIGNATURE
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Underage College Application (Chemeketa Community College)

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Completed 3 February 2021

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