Concurrent Enrollment Form (Special Admit) For Eligibility To Enroll In College Credit Courses

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Contra Costa College
Term: Fall ___ Spring___ Summer___
Year: 20____
Concurrent Enrollment Form (Special Admit)
College ID# ___________________
for Eligibility to Enroll in College Credit Courses
Grade Level: 7th, 8th, 9th, 10th, 11th, or 12th
Form must be submitted in person at the time of enrollment.
Circle One: *Level during the term of attendance
Anticipated HS Graduation Date: ______/______/______
Part I – Student
Name _____________________________________________________
Date of Birth______/______/______
Last
First
Phone___________________________________
Email Address___________________@insite.4cd.edu
I authorize
I do not authorize Contra Costa College to release my educational records to my parent/legal guardian
(as noted below) or to my high school, if requested. Permission is only granted for the term covered by this form. I
.
understand that grades earned remain on my permanent records at Contra Costa College
Student’s Signature_X_________________________________________
Date____________________________
Part II – Parent/Guardian
I am the parent or legal guardian of the above named student. I acknowledge that my child, as a college student, will be expected to
adhere to all college rules of conduct, as well as the expectations and responsibilities detailed on the back of this form. I understand
that in accordance with State and Federal law, I will not have the right to access my child’s records without his/her written consent
or court order. I understand that CCC reserves the right to deny admissions to a specific course.
Parent/Guardian Name_______________________________________________________________________________
Parent/Guardian Signature_X___________________________________
Date____________________________
Part III – Principal’s Recommendation & Certification
The above named student meets all the following criteria as defined by Education Code 48800.5 and 76001:
Demonstrates adequate preparation in the discipline to be studied.
Is able to benefit from college instruction.
For Summer Students ONLY:
This recommendation does not exceed five
percent of the students at the same grade level.
The student has exhausted all opportunities to enroll
in an equivalent course, if any, at his/her school of attendance.
Approved Courses: (required) must be completed by principal or designee.
***Incomplete forms will be withheld by A&R and a new form provided.***
Course #
Course Title
*Desired Section #
Late Add Code or Instructor
(Ex. Math-118)
(Ex. intermediate Algebra)
(Ex. 0001)
Signature
*Students are permitted to enroll in another section of the same course if the section they have listed is closed.
Principal’s Signature (or designee) _X______________________________
Date____________________________
^ Name of School: ______________________________________________
Phone___________________________
^ If home schooled, please attach a Private School Affidavit.
Processed by:_________________ Date:________________

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