Application for Admission

Candidacy Information

In which academic year will you first register for classes at Chipola College?

In which term will you first register for classes?

If applying for Fall 2018 Term C choose "Fall Term"

What type of enrollment do you plan to pursue at Chipola College?

Undergraduate = Credit Hours, typically towards a degree

Continuing Education = Short Courses and CEUs

Workforce = Clock Hour Certificate Programs and Specialized Training

What type of student are you enrolling as?

What is your planned Major/Program of Study?

Degree

Auto filled based on answer to previous question

Stage

Auto filled based on answer to previous question

Biographical Information

Social Security Number

Confirm Social Security Number

Birth Date

Legal First Name

Legal Middle Name

Legal Last Name

Suffix

Preferred First Name

What is your birth/maiden name?

Please provide names by which you have been known or under which you enrolled at previous educational institutions

Gender

Ethnicity

Race (Choose one or more)

What is the highest level of education for your parent/guardian 1?

What is the highest level of education for your parent/guardian 2?

Are you the parent of child under 18 living in your home?

Citizenship Information

Select your US citizenship status

Select your country of citizenship

If you are here on a visa, what type of visa is it?

Copy of Passport, Visa and/or Alien Card required. Contact Admissions Office for additional information.

Military Information

Are you the spouse or dependent of a Veteran or Active Duty person?

United States Veteran?

For what branch of the military are you a veteran?

Are you currently on active duty?

For what branch of the military are you currently on active duty?

Are you active in the National Guard?

What National Guard State do you serve?

Are you in the Reserves?

Service Begin Date

Service End Date

Service Exit Status

Contact Information

Permanent Country

Permanent Address Line 1

Permanent Address Line 2

Permanent City

Permanent County

Permanent State

Permanent Zip Code

Permanent Phone Number

Mobile Phone Number

Confirm Mobile Phone Number

Would you like to receive text messages regarding your application, financial aid and important dates and deadlines?

By selecting yes, you agree to opt-in to Chipola College text message application alerts. These text messages will be limited to information about your application, financial aid and important dates and deadlines. We will not send marketing materials via text messages. If you would like to opt-out of this program at any time, simply text the word STOP. Please be advised that message and data rates may apply.

Email Address

Confirm Email Address

Mailing Contact Information

Mailing Address Line 1

Mailing Address Line 2

Mailing City

Mailing State

Mailing Zip Code

High School/GED Information

Date I have completed or will complete high school?

Do you have a GED?

GED Test Date

GED Testing Center State

Chipola College Information

Have you previously applied to our school?

What year did you apply to our school?

Were you previously enrolled for credit at our school?

Other College and University Information

List all previously attended colleges and universities starting with the last college or university first.

Do not abbreviate

All degree seeking applicants are required to have FINAL OFFICIAL transcripts from EACH previously attended college forwarded directly from the issuing institution to the Admissions Office in order for your application to be considered.

State of Institution

Institution

Name of Institution

Degree

You must click SAVE after putting in each college or university previously attended.

Dual Enrollment/Early Admit Student Agreement

We are pleased that you have made this academic choice and encourage your full participation in this educational experience. To assure understanding of policies and procedures regarding conduct, curriculum, and communication you are asked to read and abide by the following:

I understand that I will be enrolled in college courses. The depth, breadth, rigor and pace of college courses will be at the college level. While appropriate for college-level study, course materials/class discussions may reflect topics not typically included in secondary courses which some parents may object to for “minors.”  Courses are not “brought down” to high school level to accommodate variations in student age and/or maturity. I understand that as a dually enrolled high school student in college courses I am subject to the same standards, policies, and responsibilities as other college students unless otherwise restricted by federal, state or local requirements. I understand that the curriculum content, evaluation, and selection of appropriate instructional materials are the prerogative of the college instructor and will not differ for dually enrolled students from that presented for traditional college students.

I understand that Chipola is an open campus and that I could be attending classes with non-high school aged students and that I may encounter students of a variety of ages and backgrounds while on the Chipola Campus.

I understand that I must agree to abide by all Chipola policies and procedures including but not limited to the Student Handbook, attendance policies and discipline policies as published. The only excused absences are those sanctioned by Chipola College. High school activities are not excused for students enrolled in classes at Chipola.

I understand that college credits earned under this program will be entered on my Chipola College transcript as well as on my high school transcript.  The college grading policy will be used for all dual enrollment courses.

I understand that I can participate in the Dual Enrollment Program for a maximum of three years. Classes must be satisfactorily completed prior to high school graduation in order to count as high school credit and be covered by the agreement. Provisional college credit will be granted for work satisfactorily completed and final credit granted after I earn a high school diploma or equivalent.  

I understand that if enrolled as an Early Admission student I must enroll and maintain fulltime status and cannot be concurrently enrolled in virtual high school or another college. I can participate in the Early Admission Program for a maximum of one year (equivalent of 12^th grade).

I understand that as a Dual Enrollment Student I am responsible for completing the appropriate college forms and meeting college established deadlines for withdrawal and/or resignation from class(es). The college calendar, dates, and deadlines are available in the college catalog, student handbook/planner, and online at www.chipola.edu.

I understand that if I wish to drop, withdraw, or resign from a class I must submit a written request approved and signed by the high school Guidance Counselor to the Admissions and Records Office by the published deadline. Students are not allowed to audit classes.  NOTE: Jackson County and Washington County do not allow withdrawals or audits.

I understand that I may not repeat college credit or workforce development courses in which I have earned a grade of W, D, or F until after high school graduation.  All grades including “W” for withdrawal, become part of the student’s permanent college transcript and may affect subsequent postsecondary admission.

I understand I cannot re-take classes in which a grade of “C” or higher has been earned.

I understand the Gordon Rule (6A10.030) requires all Florida college students to make at least a “C” in each Math, English, and Writing course; however, all grades are calculated in a student’s GPA and will appear on his/her transcript.

I understand that I must maintain a minimum term and cumulative College grade point average of 2.0.  Failure to meet this requirement will result in academic suspension until after high school graduation.

I understand that if I resign from a public high school or receive a GED during the time I am enrolled in this program I will be liable for all fees and cost for that term.     

I understand that I am responsible for requesting a final official high school transcript to be sent to the Admissions and Records Office denoting graduation and for submitting official college transcripts from any colleges I have attended.

I understand that I must complete a Residency Declaration for Tuition Purposes after high school graduation.  Failure to submit will result in being classified as out-of-state for tuition purposes, which may impact eligibility for Florida Scholarships and a higher tuition rate.

My parent/guardian and I have read and understand this student agreement.

Disciplinary History

Answer the next two questions.  If your answer to any of the following is yes, you must submit a full statement of relevant facts by requesting a Disciplinary Disclosure Form from the Admissions Office.  Failure to answer the questions below will delay processing your application.  You may be required to furnish the college with copies of all official documentation explaining the final disposition of the proceedings.  If your records have been expunged pursuant to the applicable law, you are not required to answer yes to these questions.  If you are unsure whether you should answer yes to #1 or #2, we strongly suggest that you answer yes and fully disclose all incidents.  By doing so, you can avoid any risk of disciplinary action or revocation of an offer of admission.

Disciplinary Disclosure Form Link

Are you currently or have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any educational institution?  (if Yes, you must submit a full statement of relevant facts by requesting a Disciplinary Disclosure Form from the Admissions Office.)

Have you ever been charged with a violation of the law which resulted in, or, if still pending, could result in probation, community service, a jail sentence, the revocation or suspension of your driver's license (including traffic violations which resulted in a fine of $200 or more)?  (If Yes, you must submit a full statement of relevant facts by requesting a Disciplinary Disclosure Form from the Admissions Office.)

If you answered Yes to either questions above, please upload your completed Disciplinary Disclosure form.

Residency Documentation

Dual Enrollment Residency Notice:

Dual enrollment students are not required to complete a Residency Declaration for tuition purposes per F.S. 1007.271. Fees for dual enrollment students are deferred/waived. However, after high school graduation the Residency Declaration must be submitted for tuition purposes. Failure to submit the Residency Declaration will result in being classified as out-of-state for tuition purposes, which may impact eligibility for Florida Scholarships and higher tuition rate.

Chipola College, being a state-supported college, is required to verify the eligibility of students receiving the Florida (Alabama or Georgia) resident tuition rate. The non-Florida resident tuition rate is approximately four times the resident tuition rate. Alabama and Georgia residents meeting the residence criteria may also quality for Florida tuition plus a $1 differential. Each applicant must complete a Residency Declaration form prior to the first day of the semester for which Florida (Alabama or Georgia) residency for tuition purposes is sought or residency cannot be granted for that semester. It is each student’s responsibility to verify that he/she is a Florida (Alabama or Georgia) resident.

Florida Statute 1009.21

State Board of Education Rule 6A-10.044

Your residency status will be Non-Resident for Tuition Purposes and you will be charged out-of-state tuition until the Residency Declaration form is received and verified by the Admissions and Records Office. You must complete and submit the Residency Declaration form prior to the first day of classes.

Download link to Residency Declaration Form

Submit to the Admissions and Records Office,

Email:    admissions@chipola.edu   Subject: Residency

or

Mail:       Residency Declaration

                Admissions and Records

                3094 Indian Circle

                Marianna, FL 32446

For tuition purposes, you will be charged as a non-resident student at Chipola College until you complete and submit the Residency Declaration form to the Admissions and Records Office.

Please upload your completed Residency Declaration form.

Please upload your first proof of residency (Proof 1).

Please upload your second proof of residency (Proof 2).

Attendance at Chipola College is a privilege, and in order to maintain the College ideals of scholarship, character and personality, the right is reserved to require the withdrawal of any student at any time for violation(s) of College policy, procedure, State Board Rule(s) and State of Florida Law. Each student, by registering, assumes the responsibility to become familiar with and to abide by the general regulations and rules of conduct. Rules of conduct are outlined in the student handbook. Handbooks are available at various locations throughout the college.

Notice of Equal Access/Equal Opportunity and Nondiscrimination

Chipola College does not discriminate against any persons, employees, students, applicants or others affiliated with the college with regard to race, color, religion, ethnicity, national origin, age, veteran’s status, disability, gender, genetic information, marital status, pregnancy or any other protected class under applicable federal and state laws, in any college program, activity or employment.

Title IX of the Education Amendments of 1972 (20 U.S.C. ss1681) is an all-encompassing federal law that prohibits discrimination based on the sex of students, employees, and third parties when appropriate, of educational institutions, which receive federal financial assistance.  Sexual harassment of students, which includes acts of sexual violence, is a form of sex discrimination prohibited by Title IX.  Chipola College complies with all aspects of this and other federal and state laws regarding non-discrimination.

Questions about compliance with Title IX or a complaint regarding harassment or discrimination, including sexual harassment and sexual violence, should contact the College’s Equity Officer and Title IX Coordinator:

Wendy Pippen, Associate Vice President of Human Resources, Equity Officer and Title IX Coordinator, 3094 Indian Circle, Marianna, FL  32446, Building A, Room 183A, 850-718-2205, pippenw@chipola.edu

I certify that all information given on this application is complete and accurate. I understand that any misrepresentation of facts may result in the immediate cancellation of my registration and my credits earned.

I understand and agree that I will be bound by the College's regulations as published in the College Catalog and the College Handbook.

I understand that Chipola College collects Social Security Numbers as authorized by Florida Statutes (1008.386) as a means of student identification to avoid duplication, and other uses such as the Hope Tax Credit (USC Title 26) and Financial Aid processing (34 CFR, Sect. 668.36).  The IRS requirement makes it necessary for colleges to collect the Social Security Number of every student.  A student may refuse to disclose his/her Social Security Number to the College, but refusing to comply with the federal requirement may result in fines established by the IRS.

In compliance with Florida Statute 119.071(5), the college collects my Social Security Number for use in the performance of the College's duties and responsibilities.

I understand that Chipola College's Drug Free Policy requires that the applicant pledge not to possess, sell, purchase, deliver, use, manufacture, or distribute illegal drugs or controlled substances while present on Chipola College's campuses or in attendance at any College-sponsored event.

I agree to the release of any transcripts and test scores to this institution, including any score report that this institution may request from the College Board, ACT or FLDOE.

By submitting this form, I hereby agree to abide by the above mentioned College policy, procedure, State Board Rule(s) and State of Florida Law.

Submission of this form constitutes a legally binding "Electronic Signature" which will be stored in the Chipola College Student Records System in association with this Application for Admission.

By typing my name in this textbox, I am accepting the terms and conditions outlined in the verification statement.

Student Name

By typing my name in this textbox, I am accepting the terms and conditions outlined in the verification statement.

Parent/Guardian Name