Form CCEI-SF-AU01 (rev. 09/01/2019)
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 866-878-3608 ▪ www.cceionline.edu
©
Copyright 2019, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes
no guarantee of employment, promotion, or retention.
Authorization to Release Student Information
I, ______________________________am currently (or have been in the past) a
student enrolled in __________________________________, a program offered by
Childcare Education Institute, LLC. I acknowledge that as a part of my enrollment,
CCEI maintains certain information regarding my enrollment and completion of
components of the program. I hereby authorize CCEI, its affiliates and representatives
to provide and remit to my center administration, ownership and any regional or
corporate personnel associated with the management and reporting of my education
and training as it relates to my job qualifications and the persons and entities listed
below as "Additional Authorized Recipients", in any method, whether in writing, orally or
electronically, any and all information maintained by CCEI in connection with my
enrollment, progress or completion of any program I have been enrolled in or am
currently enrolled in with CCEI. I agree to indemnify and hold harmless CCEI, its
affiliates, employees, members and representatives from any and all damages, liabilities
and costs and expenses that any of them may suffer as a result of any claim or action in
any way related to CCEI's transmittal or disclosure of information pertaining to my
enrollment in any program with CCEI in accordance with this authorization.
ADDITIONAL AUTHORIZED RECIPIENTS:
Name: ____________________________________
Name: ____________________________________
Name: ____________________________________
_____________________________________________ ___________________
Student Signature Date
SAVE FORM
SUBMIT FORM
PRINT FORM
Sends form by email to Compliance.
Print form
and fax to (866) 878-3608.
Save copy of form and upload to
Compliance in Student Portal.
