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___ Fall ___ Spring ___ Summer Year 20______ Santa Rosa Junior College Concurrent Enrollment Program Request Form

SRJC Student ID#

______________________

Last 4 of SSN

_____________

(05/13)

Student Name______________________________________________ Date of Birth______/_______/_________

Last Number/Street Home First City Cell ST Zip

Address________________________________________________________________________________________ Telephone numbers_____________________________________________________________________________ I have read the Rights and Responsibilities of Students, Standards of Conduct (available on-line @ www.santarosa.edu) and agree to abide by them. Student Signature*__________________________________________________ Date______________________

High School Certification We certify that the above named student meets all of the following criteria as defined by California State Education Code 48800.5 and 76001: Is able to benefit from the advanced coursework. Demonstrates adequate preparation in the discipline to be studied. AND for Summer Session Students ONLY: Has exhausted all opportunities to enroll in an equivalent course, if any, at his or her school of attendance. This recommendation does not exceed five percent of the students at the same grade level. Current Grade level_______ Estimated Year of Graduation ___________Type of School________________

Public/Private/Charter

Course(s) recommended by High School Counselor: IMPORTANT: High School students may NOT enroll in English 300 level courses regardless of assessment results. Course Title: ______________ Section Number: ___________ Units: ______ Counselor Initials: __________ Course Title: ______________ Section Number: ___________ Units: ______ Counselor Initials: __________ Course Title: ______________ Section Number: ___________ Units: ______ Counselor Initials: __________ Maximum number of units at SRJC advised by High School Counselor____________ Summer__________ Fall or Spring 9th grade students are advised to take up to 3 units; 10th grade students are advised to take up to 6 units; 11th and 12th grade students may take up to 11 units. All High School students may not take more than 5.5 units in the Summer semester. A Petition for Waiver of College Regulations may be filed for any High School student wishing to exceed 5.5 units in Summer or 11 units in Spring or Fall. High School Principal Signature*_____________________________________________ Date ______________ High School Counselor Signature*___________________________________________Date________________ Name of High School______________________________________ Telephone____________________________ *NOTE: Falsification of any signature on this form or any other form will result in disciplinary action and possible dismissal. Authenticity of signatures WILL be verified.

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___ Fall ___ Spring ___ Summer Year 20______ Santa Rosa Junior College Concurrent Enrollment Program Request Form

Parent/Guardian Portion Notice from the Director of Admissions & Enrollment

SRJC Student ID#

______________________

Last 4 of SSN

_____________

(05/13)

It is imperative to understand that, when a minor student, becomes a student at any college all rights accorded to, and consent required of, parents transfer to the student (Section 99.5 of the Family Educational Rights and Privacy Act). That is, parents do not have the right to inspect the minor student's records or gain access to information related to their attendance at SRJC. The minor's parents/guardians must present in person with the student, a signed release specifying information to be released before we will discuss or release any information related to the student. Minor students and their parents/guardians must also understand that they are entering a college environment, which is designed with adults in mind. Thus, the atmosphere of the campus in general, and of classrooms in particular, will frequently reflect an adult population.

Students and their parents/guardians should be aware that: Courses may have frank discussions about sensitive topics Audio-visual presentations may be graphic in their content Students may be exposed to vulgar language outside of the classroom Instructors cannot inform anyone, including parents, of last minute cancellations or early class releases. If classes are released early, instructors cannot sit with underage students while they wait to be picked up. Credit courses are COLLEGE coursework and will remain on the student's permanent college record (transcript) permanently. The District is authorized to evacuate students in the event of an emergency As the parent/guardian, they are not allowed to change information regarding the student's records, or allowed access to the student's records without the express written consent as described above. The student is held responsible for being aware of all College dates and deadlines and for taking necessary action before such deadlines pass.

Parent/Guardian Approval I hereby petition Santa Rosa Junior College to allow my son/daughter to enroll in Santa Rosa Junior College while concurrently enrolled in high school. I certify that I am the parent/guardian of the above named student and that I am in agreement with and give my consent for his/her attendance at Santa Rosa Junior College. By signing this, I certify that I have read the Standards of Conduct, Rights and Responsibilities of Students (available on-line @ www.santarosa.edu) and the "Parent/Guardian Portion" of this form in their entirety, and discussed them with my son/daughter. I understand all of the conditions under which my minor child is being admitted. Parent/Guardian Signature*___________________________________________Date______________________

Consent for Treatment of Minor (REQUIRED) Name of Minor______________________________________________ Date of Birth___________________ Last First I give permission for emergency first aid treatment for my minor child/legal ward. I also give my permission for him/her to be treated by a nurse, physician and/or mental health counselor in the Student Health Center at SRJC. Parent/Guardian Signature*_____________________________________ Date___________________________

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