Student Signature Page

STUDENT SIGNATURE PAGE

Student Information

Student Name:

Date of Birth:    Student ID:

Parent / Guardian (if applicable)

Relationship:    Phone:

Emergency Contact & Medical Considerations

Relationship:    Phone:

Acknowledgments and Authorizations

The signer acknowledges and affirms each of the following statements by checking the corresponding box. Each acknowledgment is a material term of enrollment and continued participation.

  I acknowledge receipt of the Student Handbook and agree to comply with all published policies, procedures, and disciplinary provisions. I understand that violations may result in discipline up to and including suspension or expulsion.

  I agree to abide by the institution's Honor Code and academic integrity policies. I understand that academic misconduct may result in sanctions affecting grades and enrollment status.

  I accept responsibility for appropriate use of technology and network resources and agree to the Technology Acceptable Use policy. Misuse may result in suspension of access and disciplinary action.

  I accept financial responsibility for tuition, fees, and other charges assessed to the student account. I understand failure to pay may result in holds on records and denial of future registration.

  I understand and will comply with attendance, participation, and withdrawal policies applicable to courses and activities. Absences may affect academic standing and course credit.

Media, Directory Information & FERPA

Directory information (name, program, participation, and similar data) may be used by the institution for official purposes. To restrict disclosure of directory information, indicate below.

  I elect to restrict directory information disclosure. I understand this restriction will limit certain institutional communications and publications.

  I grant permission for use of student image, voice, and work for institutional educational and promotional materials unless I opt out in writing to the registrar or designated official.

Consent for Emergency Medical Treatment

In the event of an emergency where the signer is incapacitated or parent/guardian cannot be reached, the institution and its agents are authorized to arrange for emergency medical treatment and transportation. The signer consents to such action and agrees to be financially responsible for emergency services provided.

If specific medications or restrictions apply, they are listed in the Medical Considerations section above.

Affirmation

By signing below, the signer certifies under penalty of perjury that the information provided on this Student Signature Page is true and correct to the best of their knowledge. The signer further acknowledges that the signer has read, understands, and accepts the policies and authorizations contained on this page. This signature authorizes the institution to take action consistent with the foregoing acknowledgments.

Signer Role (select one):   I am 18 years of age or older and am signing as the student    I am the parent or legal guardian signing on behalf of a minor

Sign Now