SPRING 2023

NON-HIGH SCHOOL PARTNERSHIP (NON-HSP) ENROLLMENT FORM

We are excited that you are interested in taking courses at Chaffey College! Use this form to select the course options you are interested in registering for.

ATTENTION: PLEASE READ BEFORE BEGINNING

Complete a Chaffey College application and receive your 7-digit Chaffey College ID#. College ID numbers begin with "0" and contain no letters or spaces. Enrollment forms with missing, incomplete, or incorrect ID numbers will not be processed. (Need to apply? Watch our application tutorial)
Fill out this Non-High School Partnership (NON-HSP) Form completely. Sections with a red asterisk (*) must be completed to submit the form.
It is the responsibility of the student to SELF-REGISTER for the approved course(s) they plan to take.
Confirming your enrollment: You must check into your course in Canvas on the first day of class (found on the homepage of the student portal) and complete the first assignment to confirm your enrollment or you may be dropped.
Students who complete the Non-HSP process and self-register are responsible for the cost of college service fees ($15-20) and the cost of textbooks.
If you would like to explore course options and/or create an educational plan, please make an appointment with a Dual Enrollment Counselor.

HAVE QUESTIONS? NEED ENROLLMENT SUPPORT? Our Dual Enrollment Team is here for you! (Dual Enrollment LinkTree)

Have you previously submitted an approved Non-HSP enrollment form for this requested term/semester?*

Yes No

ATTENTION

Admissions and Records will only process ONE approved Non-High School Partnership (Non-HSP) enrollment form per semester/term. Subsequent

submissions of this form will not be considered. Additional course requests/changes must be made using the "Change Form".

Which high school do you attend?*

Your current high school

ATTENTION

You have indicated "other" under the high school of attendance field. Please complete the following below.

Click Here

HIGH SCHOOL PARTNERSHIP

Your selected high school also offers HSP courses. Are you interested in enrolling?*

Yes No Whats HSP?

High School Partnership (HSP) courses are free Chaffey College courses with a $0 book material cost. If you attend a high school in one of the following school districts: CJUHSD, CVUSD, FUSD, OR UUSD, go to the High School Partnership (HSP Agreement Form) to see if the class you are interested in registering for is available through HSP.

Click the link below

High School Partnership (HSP Agreement Form)

HIGH SCHOOL INFORMATION

Please upload a current Private School Affidavit and a Transcript signed and dated by the Director or Principal Officer. Your Director or Principal Officer will also be required to digitally sign and type their name below.

Upload Home School Affidavit from the California Department of Education*

No File Chosen

File uploads may not work on some mobile devices.

Upload Transcript with Director/Principal Officer Signature*

No File Chosen

File uploads may not work on some mobile devices.

Director/Principal Officer: Please type your name below if you approve this student to enroll in the courses listed on this agreement form*

First Name

Last Name

Date/Time of homeschool administrator electronic signature*

HIGH SCHOOL INFORMATION

ATTENTION

Your high school is not currently available through our designated drop-down options. Please click and submit the form below to continue your Non-HSP enrollment process;

CLICK HERE TO GET STARTED!

STUDENT INFORMATION

Student's Name*

First Name

Initial (optional)

Last Name

Chaffey College ID#*

7 digit number starting with 0. Do not include initials or a CCC ID#.

Date of Birth*

Age

Personal E-mail Address*

Do not use e-mails provided by schools. The Admissions and Records (A&R) Department will send a follow-up email advising what course you are approved to take and eligible to self-register in.

Student's Cell Phone Number

Cell Phone Provider

Type Cell Phone Provider

Current Grade Level*

9th 10th 11th 12th Other

Please select the grade that you will be in when taking the Chaffey course.

"Other" Grade Level

8th 7th 6th

(Students may enroll as a 6th-8th grade student IF approved through the High School Student Appeal Petition - linked below)

Students who do not meet the grade-level requirement may submit an Appeal Form to the Dual Enrollment Appeals Committee. Please read below for further instructions.

Students must submit a Dual Enrollment E-agreement (this is the enrollment form you are currently filling out) for the term requested in the appeal.
Submitting an Appeal Form and having it approved, does not guarantee that you will be able to participate in the Dual Enrollment Program.
A separate appeal is required for each semester/term of enrollment.
Within 10 business days of receiving the completed form back from the school counselor/administrator, a comprehensive overview will be conducted by the Appeals Committee.
The decision of the Appeals Committee is final.

Current School ID#*

RECOMMENDED COURSES

PLEASE ENTER THE CHAFFEY COLLEGE COURSE(S) YOU WOULD LIKE TO REGISTER FOR

View Chaffey College's open class list here.

1. Course Subject *

1. Course Abbreviation & Number*

Please do not provide 5 digit section number

Warning: Students must be in 12th grade and have a Chaffey College letterhead from the KINACT coach for course approval.

2. Course Subject

2. Course Abbreviation & Number

Please do not provide 5 digit section number

Warning: Students must be in 12th grade and have a Chaffey College letterhead from the KINACT coach for course approval.

Request Additional Courses?

3. Course Subject

3. Course Abbreviation & Number

Please do not place 5 digit section number

Warning: Students must be in 12th grade and have a Chaffey College letterhead from the KINACT coach for course approval.

4. Course Subject

4. Course Abbreviation & Number

Please do not place 5 digit section number

Warning: Students must be in 12th grade and have a Chaffey College letterhead from the KINACT coach for course approval.

Please Upload Chaffey College Letterhead From KINACT Coach*

No File Chosen

File uploads may not work on some mobile devices.

STUDENT AGREEMENT

Admission requirements for high school students are:

Be in the 9^th-12^th grade

I understand that I will be held to the following student responsibilities:

I may not enroll in more than 11.5 units in any Fall/Spring semester, or 7 units in Summer term.
- Students may take more than 11.5 units (Fall/Spring) IF approved through the High School Student Appeal Petition.
I must pay for all applicable fees associated with my courses at the time I register, or I may be dropped from my course(s).
I should complete the online Dual Enrollment Orientation.
My High School Counselor/Designee will discuss any issues with the selected degree-applicable courses and/or my eligibility to take the courses.

Submissions will be routed to the counselor/administrator at your school for approval of the course options you have selected. Once the form has been processed by your high school, you will receive an email confirming what course(s) you have been approved to self-register in.

IMPORTANT: It takes our Admissions and Records Department approx. 3 business days to process approved forms and clear you to register. Students attempting to register before then, or attempting to register for a course they have not been approved to take, will receive an error code.

During the application process, the enrollment status of " Enrolling in high school (or lower grade) and college at the same time" be selected for participating in the Dual Enrollment ‘Enrolling in high school (or lower grade) and college at the same time’. By signing this form, you authorize Chaffey College's Admissions and Records to change your enrollment status to this designation, if necessary.

must be selected for participating in the Dual Enrollment ‘Enrolling in high school (or lower grade) and college at the same time’. By signing this form, you authorize Chaffey College's Admissions and Records to change your enrollment status to this designation, if necessary.

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

*

I have read and understand the responsibilities above

Student's Signature*

[clear]

Use your mouse or finger to draw your signature above

Student's Signature Date*

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.

*

I the student, have read and understand the Waiver of Liability, Assumption of Risk, and Indemnity Agreement Guidelines

Student's Signature*

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Use your mouse or finger to draw your signature above

Parent's/Guardian's Name*

First Name

Last Name

Parent's/Guardian's Email Address*

Parent's/Guardian's Day Phone*

Parent's/Guardian's Night Phone*

*

I, the parent/guardian, read and understand the Waiver of Liability, Assumption of Risk, and Indemnity Agreement Guidelines

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.

Parent's/Guardian's Signature*

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Parent's/Guardian's Signature Date*

EMERGENCY INFORMATION

In the event of an 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*

HEALTH INSURANCE

Please include the student's health insurance information below.

Name of Health Insurance Company

Insurance Policy Number

Do you suffer from any medical problems?*

Yes No

Please explain the medical problem/s*

COVID VACCINE MANDATE INFORMATION

If you choose to only take online classes and utilize student services online, you do not need to provide proof of COVID-19 vaccination. Please know, however, that you will not be able to utilize any on-campus services, including the campus bookstore, without submitting proof of vaccination. The bookstore offers free shipping or contactless pick-up. All Chaffey students enrolling in and taking in-person or hybrid courses must submit valid documentation of “full” COVID-19 vaccination. This is a prerequisite that must be fulfilled by submitting your completed Center for Disease Control (CDC) Vaccination Record card through the MyChaffey Portal.

TRANSPORTATION - OMNITRANS GO SMART

Chaffey College offers the Omnitrans Go Smart Program. which enables students to ride any Omnitrans fixed route buses with their Chaffey College Student ID card for a per-semester fee of $8. 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 email;

"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 OmniTrans program, please feel to visit Go Smart Frequently Asked Questions.

ELIGIBILITY VERIFICATION

High School Counselor/Authorized School Designee

Below are the minimum eligibility requirements for high school students:

Be in the 9^th-12^th grade

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

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 or middle school Other

Do any of the recommended courses have a requirement (prerequisites/co-requisite) in-order to register for the course/s? To view college course pre-requisites in the catalog use this link: https://www.chaffey.edu/catalogandschedule/docs/catalogs/2020-2021-courses.pdf*

No Yes

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

Were any of the recommended courses changed/updated by you the High School Counselor/Designee?*

No Yes

For the student's/parent's records please provide the following: 1) Rational for changing/updating the courses OR 2) Information about prerequisites/co-requisites and additional steps to have them cleared.*

Please select students alpha grouping according to their last name*

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:*

ADMISSIONS & RECORDS

TERM*

Spring Summer Fall

YEAR*

HAS THE STUDENT SUCCESSFULLY COMPLETED THE FORM?*

Yes No

SELECT OPTION BELOW*

Student ID is incorrect Courses listed incorrectly Duplicate Enrollment Agreement

Other:

Please select your assigned alpha grouping

A-I J-Q R-Z Backup

Employee Email