Kirkwood High School Distance Learning
Registration Form ~2015-16~
For current high school students needing credit recovery, credit advancement, or other courses unable to fit in
the traditional school day.
(Page 1 of 2)
Student Information
Last Name
First Name
Middle
Initial
Address
City
State
Primary Phone Number
E-mail (Primary)
Birth date
Gender
Ethnicity
Male
Hispanic
Female
Non-hispanic
Prefer Not to
Answer
Social Security Number
Zip
Race
American Indian/Alaska
Native
Asian
Black/African American
Native Hawaiian/Pacific
Islander
White
Prefer Not to Answer
Parent Information
Parent E-mail (Optional)
Parent Phone (Optional)
Course Information
Kirkwood HSDL strongly encourages students to limit enrollments to no more than two (2) courses at one time.
* online only
+ correspondence only
Course #1
Course #2
! correspondence course updated in 2015
Semester
** 2nd semester correspondence only
Type
1
Correspondence
2
Online
Semester
Type
1
Correspondence
2
Online
Terms & Conditions
By checking this box, I understand that I need to have a valid e-mail address and complete at least one assignment weekly. I authorize Kirkwood Community
College HSDL to provide information to the school and to the e-mail addresses provided regarding enrollment status, grades, and credit. I understand that
these courses are for HIGH SCHOOL credit.
Student Signature
Date
Parent Signature (if under 18)
Date
Kirkwood High School Distance Learning
Registration Form ~2015-16~
For current high school students needing credit recovery, credit advancement, or other courses unable to fit in
the traditional school day.
(Page 2 of 2)
School Information
School Name
School Address
City
State
School Phone
School Web-Site
CEEB Code (ACT Number)
Zip
Proctor Information
One proctor is required, but more than one proctor is acceptable. Proctors will monitor student tests and ensure they are taking them closed note, closed book.
They will sign the first page of the test upon student completion and will return tests to the HSDL Office. They are the point of contact in the event Kirkwood HSDL
has questions. Tests are e-mailed to proctors.
Proctor 1 - Name
Proctor 1 - E-mail
Proctor 2 - Name
Proctor 2 - E-mail
School District Information
If district address is the same as the school address check this box.
School District
Address
District Office Phone Number
City
Bill the School
State
Zip
Accommodations Need
Yes
Yes (Please provide appropriate documentation)
No (Registration will not be processed until payment is received)
No
Terms & Conditions
By checking this box, the school district accepts responsibility for granting student credit upon completion of the course (Kirkwood HSDL will send a
recommended grade to the proctor), providing or approving an acceptable proctor, and monitoring student progress during their four (4) months to complete the
course.
School Official Signature
Kirkwood HSDL
6301 Kirkwood Blvd. SW
Cedar Rapids, IA 52404
319-784-1517
319-398-1049 (fax)
hsdl@kirkwood.edu
Date
Fees Per Course
Reason For Taking Course
Testing location
$175 per semester (in-state tuition)
Credit Advancement
KLIFE
$125 per trimester (in-state tuition)***
Credit Recovery
Proctor at School
$225 per semester (out-of-state tuition)
Other
School Approved
Proctor**
$175 per trimester (out-of-state tuition)***
$60 book deposit*
$15 lab book fee*
* Please check www.kirkwood.edu/hsdl to see which courses require books.
**Proctor agreement form must be completed by proctor and school if not testing at Kirkwood Center for Life Long Learning or at a student's local high school.
***Trimester courses are only available in correspondence courses. No online course will be available for trimester credit.
Same day registrations available by appointment only between the hours of 8 AM & 3 PM Monday through Friday.