Valley Now! Concurrent Enrollment Student Questionnaire

We're so excited you are interested in participating in the Valley Now! High School Partnership Program for the 2023 Spring Semester. This step takes about an hour to complete, so please make sure you have set aside enough time to get everything done. If you're a high school student, you may want to have a parent or guardian nearby so you can ask them questions. The Concurrent Enrollment Student Questionnaire has several parts, so please make sure you get all the way to the end.

Student Information

First Name*

Middle Name

Last Name*

What is your Date of Birth?*

This is the day, month, and year you were born.

Oh no!*

It looks like the date you provided as your date of birth indicates you are less than 10 years old. In order to participate in the Valley Now! High School Partnership Program you need to be in high school.

I'll fix it!

As of today, are you over 18 years old?*

Yes, as of today I am over 18 years old.

No, as of today I am not over 18 years old.

What is the name of your High School or Adult School?*

Select or enter value

What grade will you be in during the 2023 Spring semester?*

If you will be in the 9th grade, or a Freshmen, please select 9. If you will be in the 10th grade, or a Sophomore, please select 10. If you will be in the 11th grade, or a Junior, please select 11. If you will be in the 11th grade, or a Senior, please select 12.

Email Address*

Please make sure to list an email address that can receive messages and you check frequently. If there is a problem with the concurrent enrollment packet you submit below, we'll email you at this address.

PLEASE DO NOT PROVIDE ICLOUD EMAIL ADDRESSES (emails from our office don't get through).

PLEASE DO NOT LIST THE EMAIL ADDRESS PROVIDED BY YOUR HIGH SCHOOL OR ADULT SCHOOL.

Please provide your street address.*

For example: 123 Main St., Apt H2.

City*

Zip*

Student's Phone Number*

Phone

If you have and know your SBVC ID#, please provide it here

Since this questionnaire is the first step in the process, you may not have an SBVC ID# yet. If that's the case, just leave this question blank. However, if you have an SBVC ID# and know what it is, please list it in the box below. Please note: your SBVC ID# is different than your high school or adult school ID#. SBVC ID numbers are 7 digits long and do not have any letters.

Parent/Guardian Information

If you're under 18 years old, you must complete this section.

Parent/Guardian Information*

Students need to provide information for at least one Parent or Guardian. Please select what information you would like to provide:

Father/Guardian Information

Mother/Guardian Information

Both Father/Guardian and Mother/Guardian Information

Father's/Guardian's Name*

Father's Home Phone #*

Phone

Father's Work Phone #

Phone

Father's Cell Phone #

Phone

Mother's/Guardian's Name*

Mother's Home Phone #*

Phone

Mother's Work Phone #

Phone

Mother's Cell Phone #

Phone

Emergency Contact Name*

Please provide the name of someone we should contact in case of emergency.

Emergency Contact Relationship*

Emergency Contact Cell*

Phone

Would you like to provide information about your Primary Care Physician?*

Yes

Physician's Name*

Physician's Phone*

Phone

Would you like to provide information about your Medical Insurance?*

Yes

Medical Insurance Company*

Medical Insurance Subscriber #*

Please list any medical conditions we should know about in an emergency:*

Are there medications the student takes regularly?*

Yes

Please list the medications taken regularly by the student:*

Does the student have any allergies to medications or other substances?*

Yes

Please list the student's allergies:*

Over the Counter Medication Consent*

In the event that a parent/guardian cannot be reached, does the staff of the SBVC Student Health Office have permission to give the student over-the-counter medication for symptom relief?

Yes

Concurrent Enrollment Course Information

For this section, please tell us which Valley Now! courses you'd like to take. Please note, in order to participate in the Valley Now! Program, you must take at least one course planned in partnership with your high school. Please also note that selecting a course below does not guarantee you will get a spot. Classes may fill before you register - so please make sure to keep an eye on your email and respond to correspondence from the Valley Now! team as soon as possible. If you're not interested in any of the courses planned through the Valley Now! High School Partnership Program, you need to contact the our Admissions department at admissions@valleycollege.edu for information and paperwork.

Please list the total number of SBVC courses you plan to take for the 2022FA semester.*

For the 2022FA Semester, most students can take up to 11 units in accordance with Education Code 76001 (d). In rare cases where students are only taking courses offered as part of a CCAP partnership, students may take up to 15 units in compliance with California Assembly Bill 288.

Please list the total number of SBVC courses you plan to take for the 2022FA semester.*

Please list the course subject, course number, and title*

Example: ENGL-101: Freshmen Composition Please Note: the Valley Now! Office is unable to provide information on courses selected outside of the list above. For important course information (such as prerequisites, course dates, times, etc), students should consult the SBVC website at www.valleycollege.edu

Please list the course subject, course number, and title*

Signature Collection

In order to take concurrent enrollment courses at SBVC, your concurrent enrollment packet must be signed by you, a parent/guardian (if you are under 18), and your principal or their designee. There are two ways we can collect this paperwork.

Option 1: Email Method After you've applied to SBVC, the Valley Now! team will email a pdf copy of your concurrent enrollment packet to the email address you provided above. You will have to download the forms and sign as the student and, if needed, secure your parent/guardian's signature.

These signatures can be added using adobe or a third-party application like Kami. You also could print out the forms, sign them, and then scan them into pdf using a scanner or pdf scanning app. Once signed, you will have to upload the form to a questionnaire a lot like this one (we'll send you the link in the email with the forms).

Option 2: DocuSign Method If you're under 18 and want to choose this method, you will need to provide a working email address for your parents. If you choose this method, once you've applied to SBVC and all your information has been verified, we will send the necessary forms to you to be signed via DocuSign. You'll receive an email with a link and you will just have to click a few places to sign the documents. If you're under 18, your parent/guardian will also get an email with a link so they can sign.

How would you like to submit signatures?

DocuSign Method

Email Method

How would you like to submit signatures?*

DocuSign Method

Email Method

Please provide the name of the person who will sign as your Parent/Guardian*

Please note: this name should match one of the names you listed above in the Parent/Guardian Information section.

Please provide the email address of the person who will sign as your Parent/Guardian*

Please make sure this is a working email address. This address MUST be different than the one you provided above.

Your parent/guardian will get an email right after you sign the documents in DocuSign. If they don't get an email right away, please contact us at ValleyNow@valleycollege.edu

Good job - but you're not done!

You're making great progress, but don't stop here! We can't prepare your concurrent enrollment forms to be signed unless you have created an OpenCCC.net account and submitted an online application to SBVC for the semester listed above! If you haven't done that, you should do that now! Once your online application to SBVC is complete and your Concurrent Enrollment Packet has been checked for errors, we'll send you your forms out for signing according to the method you chose above. You should receive an email from the Valley Now! Team within 2 weeks, so keep an eye on the email you provided above!

Send me a copy of my responses

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