HIGH SCHOOL WORK EXPERIENCE ENROLLMENT FORM

WORK EXPERIENCE HIGH SCHOOL PARTNERSHIP (HSP)

E-AGREEMENT FORM

Which High School do you attend?*

Are you enrolling in this course as a requirement of the Upland High School TA Program?

YES NO

STUDENT INFORMATION

Student's Name (First, Middle Initial, Last)*

First Name

Initial (optional)

Last Name

Date of Birth*

Chaffey College ID# (IMPORTANT: Forms with incorrect ID numbers WILL NOT be processed - please see below)*

This is provided 72 hours after applying to Chaffey College via email. Your student ID number is a 7 digit number starting with 0 (no letters). Do not include initials or a CCC ID#.

Age

PERSONAL E-mail Address*

Do not use e-mails provided by schools

Contact Phone Number*

If Cell Phone, Please Select Provider

Type Cell Phone Provider

Grade Level*

9th 10th 11th 12th

Please select the grade level you will be in when taking the Dual Enrollment course. If you are a graduating 8th grader (incoming 9th grader), please select 9th grade.

High School ID#*

If you do not have a high school ID number yet, please provide your current ID number

Employer Information

Will you be getting paid for this work exeprience?*

For which term do you plan to enroll in this work experience course?*

Summer 2024 Fall 2024 Spring 2025

Current Job Title*

Length of Employment*

Please include years and months

Company Name and Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Name of Supervisor (First and Last Name)*

First Name

Last Name

Supervisor's Email*

Supervisor's Phone Number*

Briefly describe the job duties that you will perform for this work experience course*

Work Experience Dual Enrollment Course and Unit Information

In partnership with local high schools, a Work Experience HSP course is a selected course with space reserved for high school students, and is offered free of tuition and college fees! We offer two options for high school students:

Work Experience 97A (1 unit) - requires students to work a minimum of 54 hours at their job or volunteer position

Work Experience 97B (2 units) - requires students to work a minimum of 108 hours at their job or volunteer position

Work Experience Dual Enrollment Units and additional Dual Enrollment courses:

You are eligible to enroll in up to 11 units in the fall and spring semesters (typically 1-3 courses) and 7 units in the summer term. This would include a Work Experience course and any additional dual enrollment courses you may be taking through the Chaffey College High School Partnership (HSP) program. For information regarding additional HSP courses, please visit: https://www.chaffey.edu/admissions/dual-enrollment.php

Work Experience Dual Enrollment Approval:

Your School District Designee will determine if you are eligible and should take a Work Experience course. If there are any concerns or updates regarding your course request, your school district designee will inform you.

PLEASE NOTE: If approved, you will be automatically registered in a Work Experience course.

Please choose a Work Experience Course below:*

Once approved, YOU WILL BE REGISTERED in this class

DUAL ENROLLMENT STUDENT AGREEMENT

ADMISSION REQUIREMENTS AND DUAL ENROLLMENT POLICIES/RESPONSIBILITIES FOR HIGH SCHOOL STUDENTS

Admission Requirement:

Be in the 9^th-12^th grade

Must already be employed (paid or unpaid) or in a current internship

I understand that I will be held to the following policies and responsibilities:

By entering my name below, I hereby certify that the total number of units completed in Work Experience, including the current term, will not exceed 16 units between all community colleges in the state of California, including Chaffey College (California Administrative Code, Section 55253). I declare all information provided on Chaffey College Work Experience documentation is true and correct. I also understand that misrepresentation of information on this form or other Chaffey College Work Experience documentation shall be grounds for dismissal from and/or forfeiture of credit from the Work Experience course.
In addition to the above, I may not enroll in more than 11 units (about 3-4 courses) in any Fall or Spring semester or 7 units (about two courses) in the Summer term.
I am committed to successfully completing the courses listed and willing to access college support services (free tutoring and dual enrollment counseling) if needed.
I should complete the online Dual Enrollment Orientation.

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

WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

Hereinafter called the “Activity,” I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue the Chaffey Community College District, its officers, employees, and agents from liability from any and all claims including the negligence of the Chaffey Community College District, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in the High School Partnership/Dual Enrollment Program (the Activity).

Assumption of Risks: Participation in the Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD CHAFFEY COMMUNITY COLLEGE DISTRICT HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in the Activity and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California including Education Code Section 72640 and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read all previous paragraphs, including the waiver of liability, assumption of risk, and indemnity agreement, know, fully understand its terms, acknowledge these and other risks that are inherent to the Activity, and understand that I am giving up substantial rights, including my right to sue. I acknowledge my participation is voluntary, that I knowingly assume all such risks, and that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the extent allowed by law.

In the event of any illness or injury, I give full authority to the district staff to obtain such medical treatment and/or surgery from a licensed physician/surgeon, paramedic or hospital as deemed necessary for the welfare of my child. I acknowledge that I fully and completely understand the potential risks that may be associated with this Activity and that my child’s participation is strictly voluntary.

Additional Information - Supervision of Minors: Chaffey College assumes no responsibility for the supervision of minor students outside the classroom setting. Parents are responsible for providing transportation and ensuring their children are supervised before and after class, and if or when a class is cancelled or dismissed earlier than the scheduled time. Chaffey College will not call the parent/guardian if a student is absent, nor will we verify attendance.

Course Content: College is an adult environment with minimal supervision. Discussion topics and course materials are generally designed for adult students and may not be appropriate for younger students. Course content will not be altered to accommodate younger students.

Release of Academic Information: In compliance with the Family Education Rights and Privacy Act, I understand that Chaffey College may share my academic information with the k12 governing board designee associated with the high school noted in this form and that Chaffey College will not release any student records other than directory information to any other entity or individual, including the parent(s), without the written consent of the student.

Internet Usage: Many courses required computer lab work or research projects that could involve the Internet. Chaffey’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.

Did you read and understand the policies and responsibilities above?*

Yes, I did

By entering my name below I (the student) agree to the above terms and conditions.*

First Name

Last Name

Student's Signature Date*

WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

PARENT/GUARDIAN CONSENT

I give my consent for my child to be enrolled at Chaffey College as a special part-time student. I understand that my son/daughter is being considered for admission as a college student and will abide by all college rules, regulations, and deadlines. I understand that costs for community college courses are the responsibility of the student. In compliance with the Family Education Rights and Privacy Act, I understand that Chaffey College may share my academic information with the k12 governing board designee associated with the high school noted in this form and that Chaffey College will not release any student records other than directory information to any other entity or individual, including the parent(s), without the written consent of the student.

WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

Did you, the parent/guardian, read and understand the Waiver of Liability, Assumption of Risk, and Indemnity Agreement Guidelines?*

Yes, I did

By entering my name below I (the parent/guardian) agree to the above terms and conditions.*

First Name

Last Name

Parent's/Guardian's Signature Date*

Parent's/Guardian's Day Phone*

Parent's/Guardian's Night Phone*

EMERGENCY INFORMATION

EMERGENCY CONTACT

In the event of accident or sudden illness, Chaffey College will attempt to contact the emergency contact at the phone number(s) listed below. Please list a designated contact.

Emergency Contact's Name*

First Name

Last Name

Relationship to Student*

Emergency Contact's Phone Number*

TRANSPORTATION - 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. If you are interested in participating in this program please complete the steps below:

Register for a course
E-mail admissions@chaffey.edu
Pay $8 fee
Complete the "Student ID Card Request" form located in MyChaffey Portal.

Template for admissions@chaffey.edu e-mail:

My name is John Smith. My student ID number is 0123456. My date of birth is 01/01/2004. I would like to participate in the Omnitrans Go Smart Program and agree to pay the $8 fee.

To learn more about the program please feel to visit Go Smart Frequently Asked Questions.

ELIGIBILITY VERIFICATION

Authorized High School Designee

Below are the minimum eligibility requirements for high school students:

Be in the 9^th-12^th grade
For Upland High School Only: Must be enrolled as a Teacher's Assistant at Upland High School

Is the student enrolled in the 9th-12th grade at your high school?*

No Yes

Is the student employed (paid or unpaid) or in a current internship?*

No Yes

Do you recommend the student be permitted to take the college level degree applicable courses indicated previously?*

No Yes

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

Student does not attend our high school.

Other:

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

By entering my name below I agree to the above terms and conditions.*

First Name

Last Name

Authorized School Designee Declaration Date:*