Educational Mathematics Document

Educational Mathematics Document

Student Information

Student Name:

Date of Birth:    Student ID:

Parent / Guardian (if student is minor)

Student is under 18 years of age:

Program Enrollment & Assessment

Program / Course Name:

Course Level (select all that apply): Pre-Algebra Algebra I Geometry Algebra II Calculus

Program Start Date:    Program End Date:

Prior Academic Information

Recent Math GPA:

Placement Assessment Consent

I authorize the program to conduct diagnostic and placement assessments necessary to determine appropriate course placement and instructional supports. Assessment results will be used solely for placement, instructional planning, and progress monitoring within the educational program. I understand that results are educational records governed by institutional policy and may be shared with instructional staff as required for educational purposes.

Consent to assessment:    Preferred assessment date:

Accommodations & Medical / Emergency

Does the student require accommodations for assessment or instruction? If yes, provide details below.

Policies, Acknowledgments, and Certifications

Enrollment Terms: By enrolling, the enrolling party agrees to the program schedule, tuition obligations, and the institution's attendance and conduct standards. Tuition and fees become due according to the payment schedule above; failure to remit may result in suspension from instruction and withholding of records.

Withdrawal and Refund: The withdrawing party must provide written notice to the program administrator. Refund and credit determinations will be made in accordance with published program policy and the date on which written notice is received.

Academic Integrity: The student is expected to adhere to standards of honest academic conduct. Violations including plagiarism, cheating on assessments, or falsification of records may result in disciplinary action up to and including dismissal from the program.

Records and Privacy: Educational records generated by placement assessments and course work shall be maintained in accordance with institutional recordkeeping practice. Access to records is limited to authorized personnel with an educational need-to-know unless further release is authorized in writing by the student or parent/guardian as required by law.

Certification of Information: I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information may subject the student to administrative action.

Acknowledgements (check each to indicate acceptance):

I acknowledge the attendance and punctuality requirements.
I acknowledge the tuition, fees, and payment terms.
I acknowledge the academic integrity policy.
I consent to use of assessment results for placement and instruction.

Liability and Limited Authorization

The program shall exercise reasonable care in the conduct of instruction and assessment. The institution is not liable for incidental or consequential losses except as required by law. In the event of a medical emergency, I authorize program staff to obtain emergency medical treatment for the student and to communicate necessary medical information to emergency responders and medical personnel.

Signature and Authorization

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