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Arranged Course Form
Southeast Technical is asking you to provide private information in order to process your Arranged Course Request Form. This information will be used to determine eligibility to take an arranged course. You are not legally required to provide this information; however, the college may not be able to effectively process your request if you do not provide sufficient information. Access to this information will be limited to school officials, including faculty who have legitimate educational interests in the information. Under certain circumstances, federal and state laws authorize release of private information without your consent: to other schools in which you seek or intend to enroll, or are enrolled; to federal, state or local officials for purposes of program compliance, audit or evaluation; as appropriate in connection with your application for, or receipt of, financial aid; if the information is sought with a court order or subpoena; or as otherwise permitted by other state or federal law.
This form is used to request an arranged class be established for a student caught in extenuating circumstances who needs a specific class to graduate. It is the student’s responsibility to seek instructor/advisor approval, and bring it to the Academic Affairs Office for consideration. See Procedure for Arranged Courses for detailed procedures.
Today's Date:
(mm/dd/yyyy)
Academic Affairs approval Signature:
New Course ID:
Today's Date:
(mm/dd/yyyy)
Advisor Signature:
Today's Date:
(mm/dd/yyyy)
Instructor Signature:
Today's Date: (mm/dd/yyyy)
Student Signature:


Instructor Information:

Indicate which type of arranged course is requested:

Sec.95(stacked, unpaid) OR Sec.99(extra time, paid)

I agree to develop a plan with the student to ensure the course is covered and the measurements of progress are documented.

If 'NO', why is it necessary to take the course this term?
I agree to work with the instructor on a regular basis to complete the course requirements in a timely manner. I understand I will be registered into this course and financially obligated for all cost associated with the course.
Student Information...
Administration Information...
Advisor Information...
If 'YES', why is a special arrangement required?
Semester:
StudentName:
Course Title:
Instructor:
Semester Year: (year example: 2005)
Student ID#:
Course Number:
Is the course offered this term?YesNo
 
Is this course a graduation requirement? Yes No     Is this course needed to graduate this term? Yes No
Student Advisor approval (if different than the instructor)