Education Supplement

EDUCATION SUPPLEMENT

Student Information

Student Full Name:

Date of Birth:    Student ID:

Program Enrollment Information

Program of Enrollment:

Expected Start Date:    Tuition Amount (if applicable): $

Parent / Guardian Information (if student is a minor)

Relationship to Student:    Primary Phone:

Emergency Contact / Authorized Pick-Up

Relationship:    Phone:

Medical Information & Authorization

Primary Care Physician:    Phone:

I authorize the school to obtain emergency medical treatment for the student when the parent/guardian cannot be reached. I understand that the school will attempt to contact listed emergency contacts and that I am responsible for all costs associated with such treatment.

By checking this box I provide consent for emergency medical treatment as described above.

Records & Media Release

Records Release: I authorize the release and exchange of educational records between this institution and previously attended schools, placement agencies, or accrediting entities as necessary for enrollment, credit evaluation, and placement. This authorization extends to transcripts, disciplinary records, health records required for enrollment, and special education documents where applicable.

By checking this box I authorize release of records as described above.

Media Release: I grant permission for the student to be photographed, filmed, or interviewed for use in school publications, promotional materials, and educational media. I understand no remuneration will be provided.

By checking this box I consent to the media release described above.

Academic Policies Acknowledgment

I have read and acknowledge the institution's attendance, grading, and student conduct requirements applicable to the enrolled program. I understand that failure to comply with policies may result in academic sanction, dismissal, or loss of privileges. I accept responsibility for reviewing the student handbook and any program-specific rules provided by the institution.

By checking this box I acknowledge the above academic policies and agree to comply with program requirements.

Additional Information

Certifications

I certify that the information provided in this Education Supplement is true, complete, and accurate to the best of my knowledge. I understand that intentionally providing false information may result in denial of enrollment, disciplinary action, or withdrawal of admission. I accept financial responsibility for tuition and fees in accordance with the institution's published policy and any agreed payment plan.

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