HIGH SCHOOL CERTIFICATION / EMERGENCY FORM (For Online

HIGH SCHOOL CERTIFICATION / EMERGENCY FORM (For Online Applicants ONL Y)
ST UDE NT NAM E:
C HAFFE Y I D# o r S S #
TERM/ YE A R
PART A: HIGH SCHOOL PRINCIPAL’S RECOMMENDATION AND CERTIFICATION
The student identified on this enrollment form has completed the 10th Grade and has maintained an overall grade point average of at least
2.50. My evaluation of the student’s readiness for college work, certification of eligibility and recommendation of specific courses is as
follows:
All information must be completed by the Principal or Designee before Chaffey College can accept the form. Incomplete forms can cause delays
in processing.
***Student must p rovide an OFFIC IAL HIG H SCHOOL TR ANSCRIPT IN A SEALED ENVELOPE to verify cumu lative Grade Point Average***
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Grade Most Recently Completed: M 10th Grade (Sophomore) M 11th Grade (Junior)
Recommended Courses: (8.0 units maximum allowed per term)
Course 1
Units
Cou rse 2
Print Name o f P rincipal or Designee
Units
Co urse 3
Units
Signature of P rincipal or Designee
Da te
(
High School Name
City and State
)
Area Code
Telephone Number
PART B: STUDENT ACKNOWLEDGEMENT
I understand that pa rt icipation in this special enrol lment program p rovides me w ith an opportuni ty to enro ll in col l ege courses and to
access programs and services available to a ll Chaffey Col lege students. I fu rther understand that I am responsible for knowing and
follow ing al l college pol icies and p rocedures related to a cademic performance and student behavior as del ineated in the Schedule o f
Classes and the College Catalog.
I DECLARE UNDER PENALTY OF PERJURY THAT THE STA TEMENTS SUBMITTED BY ME ARE TRUE AND CORRECT T O THE BEST OF MY
KNOWLEDGE. A ll mate rials submit ted by me fo r purpose s of admission become the prope rty o f Chaf fey Col lege. I understand that
will ful omission o r falsi ficat ion of in forma tion, or fa ilure to repo rt changes in residence may resul t in my d ismissa l f rom Chaffey
College and the loss of uni ts earned as a resul t of such omission or fa lsif ication.
Studen t’s Legal Signatu re
Date
PART C: PARENTAL ADVISORY, EMERGENCY CONTACT INFORMATION, AND PARENTAL CONSENT
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A college is an adult environment with minimal student supervision. Discussion topics and course materials are generally designed for
adult students and may not be appropriate for younger students.
Many courses require computer lab work or research projects that could involve the Internet. Chaffey Community College District’s
computer network provides access to the Internet in classrooms, labs, and the library. The College does not block access to specific
Internet sites. As a result, it is possible for your son/daughter to reach an Internet site that you may feel contains inappropriate
material.
Classes may occasionally be dismissed early or cancelled due to an instructor’s illness or absence. In that event, transportation should
be arranged as soon as possible and an appropriate waiting area identified.
Courses taken in this program will be recorded on the student’s permanent record at Chaffey College as college credit.
Chaffey College has my permission to provide unofficial grade information to my student’s high school at the conclusion of the term to
facilitate academic planning. Note: Home-schooled students and those attending high schools outside Chaffey’s district must request
written grade information individually.
Registration is based on a priority system for continuing college students. Enrollment into desired courses is not guaranteed for new
and returning students. (High School Students are considered new students each semester for which they are applying.)
High school students are allowed to enroll in a maximum of 8.0 units per term.
Release of student information is not permitted to anyone, including parents or legal guardians (Ed Code 76243). Release of
Information forms are available in the Admissions and Records Office and on our website at www.chaffey.edu.
Your signature on this document certifies your awareness of the learning environment issues as stated above; that you have reviewed
and assessed your student’s ability to succeed in the classes listed above; and that he/she has your approval to enroll in Chaffey College
courses.
If there is an emergency requiring immediate medical attention, and a parent or legal guardian cannot be contacted, Chaffey College
Student Health Services is authorized to take whatever steps are needed to protect the health of the student. In the event of accident or
sudden illness, please contact:
(Please Print) Emergency Contact/Relationship:
Phone: (
)
(Please Print) Alternate Contact/Relationship:
Phone: (
)
Print Name o f Paren t or Legal Guard ian
Signature of Parent or Legal Guard ian
Phone Number