Consolidated Student Work Form

Consolidated Student Work Form

Student Information

Date of Birth:    Student ID:    Grade / Program:

Is the student a minor? Yes      Parent/Guardian Name (if applicable):

Work Submission Details

Instructor:    Assignment Title:

Date of Work:    Submission Date:

Written / Paper    Digital file upload    Presentation / Media    Other:

Academic Affidavit and Originality Certification

By submitting this work I affirm that the submitted material is my original work, except where clearly indicated by citation or quotation. I understand that presenting another's work as my own, in whole or in part, constitutes academic dishonesty and may result in disciplinary action, including grade sanction, failure, suspension, or expulsion. I further certify that all sources used have been properly credited and that any collaboration is explicitly described below.

I certify the work is my own original work and has been prepared in accordance with course requirements.

Rights, Use, and Publication Release

As the creator of this work I retain copyright unless otherwise agreed in writing. By checking the consent box below I grant the institution a non-exclusive, royalty-free, worldwide license to reproduce, distribute, display, and archive this work for educational, promotional, archival, and research purposes. This license does not transfer ownership; it permits use of the submitted material in institutional publications and online educational resources. I understand I may revoke publication consent in writing for future uses but that materials already published prior to revocation may continue to be used.

I grant permission for the institution to publish or display this work as described above.      I do not grant permission for publication (internal evaluation only).

If the student is a minor, the parent or legal guardian must sign below to grant the permission described above.

Instructor Assessment (for instructor use)

Grade / Score:     Plagiarism Check Performed: Yes     Plagiarism Result Notes:

Instructor Printed Name:     Instructor Date (MM/DD/YYYY):

Privacy and Recordkeeping Notice

The institution will retain records of submissions and related evaluations in accordance with applicable institutional policies and privacy laws. Access to submitted materials will be limited to authorized personnel for academic assessment, accreditation, research, and publication processes as permitted by the creator's consent. Requests to review or correct records should be submitted in writing to the appropriate academic office.

Acknowledgment and Signature

I acknowledge that I have read and understood the statements and certifications on this form. I understand the academic and legal implications of submitting work that is not my own and the terms under which I may allow the institution to use my work. If I am a parent or guardian signing on behalf of a minor, I affirm that I am authorized to provide consent on the minor's behalf.

Sign Now