Education IT Form

EDUCATION IT FORM

Use this form to request institutional IT resources, accounts, device assignment, software licensing, or network access. Complete all applicable sections. Delays may occur if required authorizations or justifications are incomplete.

Applicant / Student Information

Date of Birth:    Student ID:

Applicant is a minor:

Parent / Guardian Information (if applicable)

Requested IT Resources and Access

Select requested accounts and services (check all that apply):

Institutional Email Account

Learning Management System (LMS) Access

Network / Wi‑Fi Access

VPN / Remote Access

Cloud Storage / Collaboration

Printing / Managed Print Services

Elevated / Administrative Privileges

Special Software License   Specify:

Other (describe):

Device Request / Assignment

Device requested / assigned:

Intended use (classroom, research, remote learning, other):

Software Licenses and Data Access

List required software, license counts, and any restricted data access needed. Requests must include justification and sponsoring faculty or department approval where applicable.

Policies, Responsibilities, and Certifications

By signing below the applicant (or parent/guardian if applicant is a minor) acknowledges receipt, review, and acceptance of institutional IT policies governing acceptable use, data privacy, password management, and device custody. The applicant agrees: to use accounts only for authorized educational purposes; to protect credentials and change passwords when prompted; to report suspected compromise immediately; and not to attempt to circumvent security controls. Accounts and privileges may be suspended, revoked, or modified for policy violations.

Device assignment: The assignee accepts responsibility for physical security, reasonable care, and timely return of loaned devices. Loss, theft, or damage must be reported; repair or replacement costs may be charged when loss or neglect is established. The institution retains ownership and may collect, inspect, or reset devices for maintenance, policy compliance, or safety.

Data privacy and restricted information: Access to confidential or restricted data is limited to authorized persons and must be used strictly for institutional business. Unauthorized disclosure of personally identifiable information, protected health information, or student education records is prohibited and may result in disciplinary or legal action.

Indemnification and liability: The applicant accepts that use of IT resources is at their own risk within institutional policy limits. The institution does not guarantee uninterrupted service or loss-free storage and is not liable for personal data loss or unauthorized access resulting from user negligence.

Acknowledgments (select all that apply)

I have read and agree to comply with the Acceptable Use Policy and institutional IT security requirements.

I accept device loan terms, responsibility for care, and return conditions.

I acknowledge restrictions on access to confidential and restricted data and agree to protect such data.

I understand that IT activity may be monitored to protect institutional systems and data.

Emergency Contact

IT Office Use Only

Approval status:

Approved    Denied

Certification and Signature

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that knowingly providing false information or using institutional IT resources in violation of policy may result in disciplinary action. If signing as a parent or guardian, I certify that I am authorized to consent on behalf of the minor applicant.

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