High School Dual Enrollment Request Form

Before submitting, students and parents should review

High School Dual Enrollment (Special Admit) Important Information

Please complete the following:

FormTitle*

FormID*

School_Name*

Not your school? Hit the back button on your browser or go back to the previous browser tab to select the correct school.

Principal_email*

Principal_Name*

Home Schooled*

Student Legal Name*

First Name

Middle Name (optional)

Last Name

Do you have a preferred first name that is different than your legal name?*

Yes No

Please provide your preferred first name*

Note: in the field below you will be asked to enter your 9 digit SRJC student ID number. This number is provided on your SRJC application welcome letter. This number IS NOT located on any emails from CCCAPPLY. This number IS NOT your Application ID. This number IS NOT your CCCID. Do not submit this form until you have obtained your SRJC student ID number.

SRJC Student ID Number*

9 digit number located in your SRJC Application Welcome Letter. No dashes.

Requested semester of enrollment at SRJC*

Requested year of enrollment at SRJC*

Date of birth*

How old will you be when the semester starts?*

12 13 14 15 16 17 18 19 20 or Older

Please check the academic calendar for semester start dates to determine what your age will be: https://admissions.santarosa.edu/academic-calendar

Primary phone number*

Format: ###-###-####

Student email address*

Parent/Guardian Name*

First Name

Last Name

Parent/Guardian email address*

Confirm Parent/Guardian email address *

Make sure to type this carefully. An email of your parent is required to obtain their approval of your admission.

Can your parent or guardian receive a text message?*

Yes No

Please provide your parent or guardian's phone number that can receive a text message*

Current grade level*

Expected year of graduation*

Courses Requested

For the current schedule of classes, please refer to: https://classes.santarosa.edu/

Students are permitted to enroll in another section of the same course if the section they want to enroll in is closed. 9th grade students are advised to take up to 3 units; 10th grade students are advised to take up to 6 units; 11th and 12th grade students may take up to 11 units. All High School students may not take more than 11 units for any semester or term. High School students may NOT enroll in English 300 level courses regardless of assessment results.

I want to be able to enroll in any Dance or PE course

Yes No

If Yes, you only need to provide ONE Dance or PE course number below.

Course 1*

(Example: COUN 270) NOTE: DO NOT ENTER A SECTION NUMBER. PLEASE ENTER THE SPECIFIC COURSE NUMBER.

Course 2

(Example: MATH 15) NOTE: DO NOT ENTER A SECTION NUMBER. PLEASE ENTER THE SPECIFIC COURSE NUMBER.

Course 3

(Example: MATH 15) NOTE: DO NOT ENTER A SECTION NUMBER. PLEASE ENTER THE SPECIFIC COURSE NUMBER.

Course 4

(Example: MATH 15) NOTE: DO NOT ENTER A SECTION NUMBER. PLEASE ENTER THE SPECIFIC COURSE NUMBER.

Course 5

(Example: MATH 15) NOTE: DO NOT ENTER A SECTION NUMBER. PLEASE ENTER THE SPECIFIC COURSE NUMBER.

By signing this form I acknowledge the following: I have read the High School Dual Enrollment (Special Admit) Expectations and Responsibilities on the back of this form and agree to abide by them. I also understand that I must submit an online SRJC application for every spring or summer/fall semester in order for this form to be processed (www.santarosa.edu/apply). Further, by signing this form I authorize Santa Rosa Junior College (SRJC) to release my educational records to my high school after each semester that I attend SRJC as a high school student.*

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