KCC Dual Credit App

About You

This application will take approximately 10 minutes to complete. You will need your email address, your parent or guardian's email address, and your phone number.

Names & Demographics

First Name

Middle Name

Last Name

Previous Last Name

Preferred name

Sex at Birth

Marital Status

Birthdate

Ethnicity & Race

To comply with federal statistical reporting requirements, Klamath Community College must seek to identify the racial and ethnic background of applicants. You are encouraged to to supply this information, but your application will be given the same consideration whether or not you do so.

Ethnicity

Contact Information

Address

Country

Street

City

State or Territory

State/Territory

Zip/Postal Code

County

Are you a legal resident of OR, CA, WA, ID, or NV?

For Military personnel, base this on your home of record

Phone & Email

Mobile Phone Number

10 digits. NO Country code, spaces, or special characters.

Secondary Phone Number

Personal Email Address

example: johndoe@gmail.com, or johndoe@yahoo.com

Confirm Email Address

Email
Confirmation OK

Email
Confirmation Error

Course Information

When do you plan to start?

High School Name

Have you ever had an IEP or 504 Plan?

HS Course Title

KCC Course Title

KCC Instructor Name

KCC Course Code

Hidden fields

Academic Start Term Id

High School Id

HS Program Id

Student/Parent Acknowledgement & Signature

Both you and your parent/guardian are required to sign your acknowledgment of the statements below. Please enter your parent/guardian's full name and their email below. When you submit the form, you'll provide your full name and email to verify your signature. Once you have completed this step, your parent/guardian will receive an email to sign off on your submission.

I hereby certify that I have provided complete and accurate information on this form, and I understand that if it is found to be otherwise, it is sufficient cause for rejection or dismissal. In addition: (1) I am aware that not all colleges and universities accept dual credit coursework, (2) I understand that KCC adheres to FERPA guidelines and may release directory information, and (3) I acknowledge that I understand the grading system and drop/withdraw deadlines.

Grades may impact your High School GPA. Grades earned for dual credit courses are recorded on your Klamath Community College transcript and are subject to our Standards of Satisfactory Academic Progress. Please see website for more detail: https://www.klamathcc.edu/Admissions/Financial-Aid/Maintaining-Your-Financial-Aid/Satisfactory-Academic-Progress- Policy

Title IX

Klamath Community College is committed to creating a learning and working environment that ensures equal access and opportunity to education and resources for all of its students, free of bias, discrimination, and Course Info harassment. For details, resources, and reporting options, refer to website: https: //www.klamathcc.edu/About/Contact/Offices/Title-IX-Student-Conduct

Parent/Guardian Information

Parent/Guardian Full Name

Parent/Guardian Email for e-signature

White	Native Hawaiian or Other Pacific Islander
Black or African American	Asian
American Indian or Alaska Native