Washington County Regional Center
2016-2017 Academy Pre-Registration Form
Part I: Student Information (please print)
_________________________________________________________________________________________________________
Last
First
Middle Initial
_________________________________________________________________________________________________________
Street Address or P O Box Number
City
______________________________________
Area Code

cell
State
 home
Phone Number
Zip Code
______________________

Male

Female
Date of Birth
_________________________________________________________________________________________________________
Email Address
Name of High School
Student Accommodations:
Do you have an IEP?
Do you have a 504?
Do you have a Health Plan?
Yes
Yes
 Yes
Anticipated High School Grad Year
No
No
 No




IEP/504/Health Plan notes:
Part II: Parent Information (please print)
_________________________________________________________________________________________________________
Parent or Guardian Name(s)
_________________________________________________________________________________________________________
Street Address or P O Box Number (if different than student’s)
City
_______________________________________  cell
Area Code
Phone Number
State
 home
Zip Code
_________________________________  cell
Area Code
 home
Phone Number
Part III: Student Agreement
To be considered for this academy, I understand I must also:
1. Apply at www.kirkwood.edu/hscreditapply (by March 15th)
2. Take the Compass placement test at Washington County Regional Center OR have my ACT scores submitted to Kirkwood (by April 1st)
3. Attend a mandatory orientation the evening of April 6, 2015
*Students who complete above requirements by stated dates will be given priority registration preference.
I have read and understand that I need to complete the above requirements and be in good academic and attendance standing
for me to be considered for College Credit in High School at the Washington County Regional Center. I also understand that some
academies require Compass cut scores.
_________________________________________________________________________
Date _____________________
Student Signature
Part IV: School District Verification
I verify that the student identified on this application is eligible for participation in Washington Regional Center college credit
classes.
_________________________________________________________________________
Date _____________________
Signature of Authorized School Official
Revised 11/13/15
(over)
Part V: Selecting your Academy and Companion Courses
I am interested in the following college credit in high school academies. (Please mark 1st, 2nd, and 3rd choices). You will only be
enrolled in one. These are all year-long experiences (except where noted). Academy schedule may be subject to change.
Morning (8:30-10am)
Afternoon (12:15-1:45pm)
__ Advanced Manufacturing/Welding
__ Advanced Manufacturing/Welding
__ Architecture, Construction & Engineering
(Civil Engineering and Architecture required year-long
__ Arts & Science I
companion)
__ Information Technology
__ Hotel Management
__ Arts & Science I
__ Arts & Science II
__ Patient Care
__ Business Exploration
__ Pre-Engineering: Project Lead the Way
(Principles of Engineering required year-long companion)
__ Criminal Justice
__ Transportation: Option B – Collision
(Recommended Spring Companion: Human Relations in Mgmt.)
__ Patient Care
__ Transportation: Option A – Auto Tech
(Fall companion course not available, recommended Spring
Companion: Human Relations in Mgmt.)
__ Graphics and Media Communication
__ Emergency Medical Services (Fall semester only)
(companion course not available)
Companion Courses
(Please select your top 4 choices) – you will be enrolled in 2 courses (one fall and one spring, except where noted as yearlong).
Morning (10:05-11am)
Afternoon (1:50-2:45pm)
__ Introduction to Computers
__ Introduction to Computers
__ Introduction to Sociology
__ How College Works
__ How College Works
__ Human Relations in Management
__ Human Relations in Management
__ Social Problems
__ Exploring Teaching
__ Cultural Anthropology
__ Civil Engineering & Architecture (year-long companion)
__ US History Since 1877
__ Human Biology
__ Statistics
__ Trigonometry and Analytic Geometry
__ Calculus I
___ I will not be taking a companion course, per school district approval.
Part VI: Drop Deadline Agreement
Students, please read and initial the following statement:
I understand that by participating in a career academy at the Kirkwood Washington County Regional Center, I am making a year-long
commitment, and that I will not be able to drop courses after the May 15th deadline.
___________________ (student initials)
Completed forms should be submitted to:
Kierstan Peck
Washington County Regional Center
2192 Lexington Blvd.
Washington, IA 52353
Fax: 319-398-1043
kierstan.peck@kirkwood.edu
You will be required to attend a mandatory orientation on April 6th where you will learn more about the
Washington County Regional Center experience and student expectations.