FA22- Adult Education Dual Enrollment Agreement

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

ADULT EDUCATION DUAL ENROLLMENT FORM: FALL 2022

This form is for students who have completed Chaffey College's application and received their 7-digit Chaffey College ID#.

If you need to apply to Chaffey College, you can learn how to do so HERE. After completing the application, will receive your Chaffey College ID# in 48-72 business hours via the personal e-mail account you listed on your application.

Which Adult School or Program Do You Attend?*

Your current adult school/program

TYPE THE NAME OF YOUR ADULT SCHOOL or PROGRAM CONTACT PERSON BELOW*

First Name

Last Name

Adult School or Program Contact Person Email*

Name of Adult School or Program*

STUDENT INFORMATION

Student's Name*

First Name

Initial (optional)

Last Name

Date of Birth*

Chaffey College ID#*

This ID number is provided after you have completed the Chaffey College application

Student's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Personal E-mail Address*

Please use personal email only

Student's Cell Phone Number*

Cell Phone Provider

Type Cell Phone Provider

REQUIREMENTS AND COURSE SELECTION

Admission requirements for adult school or Adult Transition Program (ATP) students are:

Current enrollment in an adult school or the CJUHSD ATP program
Enrollment limit of 11 units in any Fall/Spring semester, or 6 units in Summer term

I understand that the classes I take will be a part of my official permanent college record and may impact my university/college admissibility.

RESOURCES

Spring 2022 Schedule of Classes

Course Descriptions

Disability Program and Services:

The Chaffey College Disability Programs and Services (DPS) is a program designed to assist students with disabilities succeed in college. It is also here to assist the instructors with students with disabilities in their classes, to better serve those students.

If you have been diagnosed with a disability OR believe you may have an undiagnosed disability that is affecting your learning experience, please contact our DPS office immediately. We recommend you speak with a DPS counselor as soon as you apply to the college and receive your student identification number to determine if you are eligible for resources.

Click her for more information:

Frequently Asked Questions

Schedule an Appointment with a DPS counselor

Please enter below the course(s) you would like to register for and the number of units associated with that course. Your adult school or program designee will determine your eligibility and approve or deny your request. If there are any concerns related to your course(s), they will inform you.

Did you read and understand the responsibilities stated above?*

Yes, I did.

1. Subject (i.e. "Accounting")*

1. Course Number (i.e. "1A")*

1. Units for Course (i.e. "4")*

2. Subject (i.e. "Accounting")

2. Course Number (i.e. "1A")

2. Units for Course (i.e. "4")

3. Subject (i.e. "Accounting")

3. Course Number (i.e. "1A")

3. Units for Course (i.e. "4")

4. Subject (i.e. "Accounting")

4. Course Number (i.e. "1A")

4. Units for Course (i.e. "4")

STUDENT AGREEMENT

VACCINATION REQUIREMENT

All students attending in-person classes are required to be fully vaccinated and submit a COVID-19 vaccine card. This includes Chaffey College classes located on an adult school. A person is considered fully vaccinated after at least two weeks of completing a two-dose mRNA series (Pfizer or Moderna) or single dose of Johnson & Johnson’s Janssen vaccine. Chaffey College students who use in-person student support services (i.e., meeting with a counselor face-to-face, visiting Financial Aid, purchasing textbooks face-to-face) are also required to submit proof of vaccination prior to coming on campus. If you believe you need an exemption from this mandatory requirement due to a medical reason or because of a sincerely held religious belief, you may submit an exemption request.

Once you submit this dual enrollment form, an email will be sent to the email listed on this form detailing how to upload your vaccination card into the Student Portal, how to submit an exemption request, as well as who to contact for assistance.

We will not be able to register you for any in-person courses without proof of vaccination.

I acknowledge that I have read the above information regarding the mandatory vaccine requirement. By typing my name in the signature field below I understand and agree that by typing my name in the signature field I am submitting it as my official signature with the same legal effect as a written signature.*

First Name

Last Name

Student's Signature *

[clear]

Use your mouse or finger to draw your signature above

Student's Signature Date*

OMNITRANS GO SMART

Chaffey College offers the Omnitrans Go Smart Program, which enables you to ride any of Omnitrans’ fixed route buses with your Chaffey College Student ID Card for a per-semester fee of $8 for a part-time student. To learn more about the program please feel to visit Go Smart Frequently Asked Questions.

If you interested in this participating in this program please complete the steps below:

Register for a course
Complete this FORM.

ELIGIBILITY VERIFICATION

Adult School/Program Authorized Designee

Below are the minimum eligibility requirements for adult school/ ATP program students:

Currently enrolled in an HSE/HSD program at an adult school or program, and will be 18 years old on the first day of attendance of Chaffey College.

Is the student currently enrolled in your school in an HSD/HSE/ATP program at your school?*

No Yes

I do not recommend the student be permitted due to:*

Student does not attend our adult school or the ATP program. Other.

Please explain why the student should not be permitted to take the college level degree applicable courses. *

By typing my full name below I affirm the accuracy of the information given in this agreement and provide my electronic designee signature verification.*

First Name

Last Name

Authorized School Designee Declaration Date:*

TERM*

Spring Summer Fall

YEAR*

HAS THE STUDENT SUCCESSFULLY COMPLETED THE FORM?*

Yes No