Fillable Waiver of Age Requirement Application for Minors to (Durham Technical Community College)

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Waiver of Age Requirement Application for Minors to (Durham Technical Community College)

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Waiver of Age Requirement
Application for Minors to Attend College and Career Readiness Program
Prior to being admitted into the College and Career Readiness program, minors must
have been withdrawn from public school for at least six months.
RETURN TO: Mr. Gregory Bellamy, Dean
Durham Technical Community College
College and Career Readiness Program
White Building (Building 1), 1-103
1637 Lawson Street
Durham, North Carolina 27703
Please attach a notarized “Parent Consent Form” and a completed “Disciplinary Disclosure Form”
to this application.
To be completed by applicant:
1. Student Name: ______________________________________ Date of Birth: ____________________
Student !ddress: ____________________________________________________________________
__________________________________________________________________________________
Student Telephone Number: _________________ Email Address: ___________________________
To be completed by school principal or other designated school official:
2. Last School Attended: _________________________________________________________________
Address: ____________________________________________________________________________
Date of Last Attendance or Official Withdrawal: _____________________________________________
3. Was the student suspended? _____ Yes _____No. If yes, how many suspensions? _______
If student is currently under suspension, when will the suspension period terminate? ______________
4. What dropout prevention services, strategies and/or initiatives were attempted but found not to be viable
for this student?
Evening School Ed. Options PLC Early College
Middle College Tutoring Mentoring Other____________________
What factors contributed to the decision that these services would not be viable for this student?
Revised 4/2018
5. What extenuating circumstances need to be considered in making a decision regarding the waiver of the
age requirement for this student?
6. In what ways has this student demonstrated that she/he is an independent learner?
▭ Self-initiating
▭ Seeks guidance to make informed decisions about his/her educational opportunities
▭ Asks for clarification when unclear about instructional content
▭ Seeks feedback from instructors to improve learning outcomes
▭ Responds positively to corrective feedback
▭ Motivated to learn for personal satisfaction
▭ Is able to identify academic strengths and weaknesses
▭ Uses time-management strategies to complete assignments
▭ Sets goals and works to achieve them
▭ Attends classes regularly
▭ Is rarely tardy
▭ Other: _____________________________________________________________
7. What responsibilities has this student maintained that indicate s/he has the maturity needed to succeed in
an adult education program? (Please provide specific examples and approximate time periods.)
Primary caregiver for own child or other family member Full-time job for at least four months
Part-time job for at least eight months Self-supporting for at least six months
Additional Information:
Signature of Superintendent or Designee
Date
or Authorized Charter School Official
Revised 4/2018
___________________________________
_______________________________
_______________________________
College & Career Readiness Program
PARENT CONSENT FOR MINOR APPLICANTS
NOTARIZED PETITION
STATE OF_______________________________, COUNTY OF_______________________
______________________________ personally appeared before me on this _________day of
(Printed Name of Parent or Guardian)
_____________, 20__ and acknowledges that he/she is the parent, legal guardian or other person
or agency having legal custody and control of ____________________________, attests that the
(Print Name of Applicant)
current place of residence of the applicant is _________________________________________
(City) (State)
and the date of the applicant’s last attendance in school was _____________________________
(Month) (Day)(Year)
at ___________________________________________________________________________.
(Name and Address of School)
The applicant is _______years of age and was born on _________________________________.
I hereby give my permission and enter this petition for him/her to take the General Education
Development Tests at Durham Technical Community College.
(Parent or Guardian Signature)
Witness my hand and official seal this _______ of ___________________________, 20_____.
(Signature of Notary Public)
Official Seal
(Commission Expiration Date)
Revised 4/2018
RETURN TO:
Mr. Gregory Bellamy, Dean
Durham Technical Community College
College and Career Readiness Program
White Building (Building 1),
1-103
1637 Lawson Street
Durham, North Carolina 27703
This section is to be completed by applicant and parent or guardian
___________________
_____/____/_____
Last 4 digits of Social Security Number
Birthdate
I am applying for admission into the College & Career Readiness program at Durham Technical Community
College. Please release all available recorded information regarding any disciplinary matters I was involved in
while attending public or private school.
To be completed by official of former high school or middle school
Student records indicate no disciplinary action or behavior problems
Student records indicate the following disciplinary action (make attachment if necessary)
Action
Duration
Date
Reasons
Suspension
Expulsion
Check all the following school policy infractions that apply to the student named above:
Fighting Alcohol Use Illegal drug use Weapons on school grounds Vandalism
Other (explain) _______________________________________________________________
Known court action: ___________________________________________________________
_________________________ _____________________
School Official’s Signature Date
_________________________ ______________________
Name of School Telephone number
Affix School Seal
Revised 4/2018
Disability Services
Students with physical, psychological, or learning disabilities may qualify for services offered
through Durham Technical Community College and/or Durham Public Schools.
Durham Technical Community College abides by Section 504 of the Rehabilitation Act of 1973, which
stipulates that no student shall be denied the benefits of an education “solely by reason of a
handicap.” Disabilities covered by law include, but not limited to, learning disabilities, psychological
disabilities, health impairments, hearing, and sight or mobility impairments. If you have a disability
that may have some impact on your work in this class and for which you may require
accommodations, please contact the Disability Services office by calling 919-536-7207,
emailing disabilityservices@durhamtech.edu, or visiting the Phail Wynn, Jr. Student
Services Center, room 10-209 for additional information regarding requirements for
arranging accommodations.
In addition, services also may be available to Gateway students through Durham
Public Schools. Services are offered through the Exceptional Children’s Department of the
Durham Public Schools and are designed to create equal access to education through the
implementation of an Individualized Education Plan (IEP) designed to provide qualifying
disabled students with a free appropriate public education. Students entering the Gateway to
College program who previously received individualized services from a public school district
through a 504 Plan or an IEP, or who suspect they may be in need of such services, may continue
to qualify for services under Section 504 or the IDEA through the Durham Public Schools, or may
request an evaluation to determine eligibility for such services. For more
information visit Exceptional Children's Services at Durham Public Schools or call Dr.
Marguerita Best 919-536-7231, ext. 2429.
It is the policy of the State Board of Education, the Community College System, Durham and Orange
county public school systems, and Durham Technical Community College to encourage young people
to complete high school, rather than to seek testing for the General Educational Development (GED)
exam or to seek admission to the Adult High School Program. All other educational alternatives
should have been explored before high school-
aged students are referred
to Durham Technical Community College.
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Waiver of Age Requirement Application for Minors to (Durham Technical Community College)

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Completed 26 July 2020

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