Klamath County School District PROGRAM NAME Program

KlamathCountySchool District:Advanced Diploma program

This form must be complete and submitted to the KCSD High School Principal the student is currently enrolled in by May 15. Failure to meet the deadline will/could prevent the student from being enrolled in the Advanced Diplomaprogram.

Section A – Completed by student (Please print or type information):

Student Full Name: / KCSD ID #
Mailing Address:
Street address / City / Zip Code
Primary email Address:
Primary Phone #: / Secondary Phone #:
Home or cell (circle) / Home or cell (circle)

Section B – Assurances to be completed by student (Please place your initials by each statement)

Student Initial

I agree and understand that by enrolling in the Advanced Diplomaprogram, I will not receive my KCSD diploma until I have completed 1-year at KCC or drop from the program.

I agree to be dually enrolled in KCSD and KCC for 1-year while in the Advanced Diplomaprogram.

I agree to enroll in KCC and maintain satisfactory academic standing to remain in the program.

I agree to maintain satisfactory academic standing or my enrollment in the Advanced Diplomaprogram will be reviewed and I may be dropped from the program.

I agreeto being registered in a minimum of 9 credit hours each term and the financial responsibility for anything over 13 credits per term will be my responsibility.

I agree to meet all of the KCC academic calendars guidelines and abide by rules and regulations of KCC while enrolled in the Advanced Diplomaprogram

I agree to complete and submit an official KlamathCommunity College enrollment application by May 15of the year of my KCSD graduation year.

I agree to complete an official withdrawal form if I choose to leave the Advanced Diplomaprogram before the completion of 1 academic calendar year at KCC.

I understand once I withdraw from the Advanced Diplomaprogram that I will not be eligible to reapply at a future date.

Section C – Required Signatures

I have read and agree to abide by all rules and guidelines of theAdvanced Diplomaprogram. I also agree to allow KCSD and KCC to exchange records and information including grades, transcripts and other documents necessary for my successful enrollment and participation in theAdvanced Diplomaprogram
Print Name Student Signature / Date
Print Name Parent Signature / Date
KCSD confirms the student listed above has met the requirements necessary for enrollment in the KCSD Advanced Diplomaprogram. KCSD agrees to cover the cost of up to 39 credit hours, books and required supplies for 3-terms in 1-uninterrupted academic year while the student is enrolled in the KCSD Advanced Diplomaprogram.
KCSD Administrator Signature / Approved / Denied / Date
Copy to KCSDHigh School and KCSD Curriculum Office / Copy to Student / Parent / Copy to KCC
Approved 10/17/12