Intensive AS Chemistry Course Enrollment Form

Intensive AS Chemistry Course Enrollment Form

Course Title:    Course Code:

Student Information

Date of Birth:    Student ID:    Grade/Program:

Is the student under 18 years of age?   If yes, parent/guardian information must be provided below.

Parent / Guardian Information (If student is under 18)

Course Details & Schedule

Section:    Start Date:    End Date:

Meeting Days / Times:

Location:    Instructor:

Modality: In-person    Online    Hybrid

Prerequisites confirmed: I have completed or possess required prior knowledge for AS Chemistry as described in the course syllabus.

Tuition, Fees, and Payment

Payment Plan Options: Pay in full at registration    Installment plan (see payment agreement)

Refund and Cancellation Policy: Tuition refunds are available only as stated in the official refund schedule. Withdrawal after the first scheduled meeting may result in partial or no refund as set by the program. By enrolling, the student or guardian acknowledges responsibility for all assessed fees unless otherwise waived in writing by the program director.

Emergency Contact & Medical Information

Student requires administration of medication during class: Yes

Academic, Safety & Conduct Acknowledgements

Academic Integrity: The student affirms that all coursework, laboratory reports, and assessments will be the student's own work, except where collaboration is explicitly authorized. Plagiarism or academic dishonesty may result in disciplinary action up to dismissal from the program.

Laboratory Safety: Participation in the Intensive AS Chemistry course requires adherence to established laboratory safety rules. The student and guardian acknowledge the inherent risks of laboratory work involving chemicals, glassware, and specialized equipment. Attendance at mandatory safety orientation is required prior to first lab session.

By checking the boxes below, the signer indicates acceptance of these policies and agreement to comply with safety protocols:
I acknowledge the Academic Integrity policy.    I acknowledge the Lab Safety policy and will attend orientation.    I will wear required personal protective equipment when instructed.

Special Accommodations

Documentation in support of accommodation requests may be required. I understand and will provide required documentation if requested.

Photo / Media Release

I grant permission for photographs, video, or other media taken in the context of the Intensive AS Chemistry course to be used by the program for educational, promotional, or archival purposes, unless I otherwise indicate below.
I consent to photo/media use.    I do NOT consent to photo/media use.

Consent, Liability & Certification

By signing below, the signer certifies that the information provided on this form is true and complete to the best of their knowledge. The signer authorizes the program to obtain emergency medical treatment if necessary and releases the program and its staff from liability for injuries arising from ordinary negligence, except for willful misconduct or gross negligence. The signer further agrees to indemnify and hold harmless the program against claims arising from the signer's actions or omissions while participating in course activities.

Enrollment is conditioned upon acceptance by the program and upon payment of required fees. Enrollment may be terminated for failure to comply with program policies or payment obligations; termination does not relieve the signer of financial responsibilities accrued prior to the effective date of termination.

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