Fillable Certificate Program Enrollment Application (ChildCare Education Institute)

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Certificate Program Enrollment Application (ChildCare Education Institute)

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Form AP-09-001 (Rev. 6/27/11) Page 1 of 2
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.edu
©Copyright 2011, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes no guarantee of
employment, promotion, or retention.
Minimum Enrollment Requirements
Applicants must:
Be 18 years of age or older
Hold a high school diploma or GED
Must be able to speak, read, and write well
enough in the language the course is presented in
to understand and complete the course material
Possess or have immediate access to a
computer, printer, word processing software, valid
and current email address, and access to the
Internet through a JavaScript enabled web
browser.
Some certificate programs have additional enrollment
requirements. Please see the CCEI website
(www.cceionline.edu) for complete details.
Certificate Program
Enrollment Application
Please type or print in ink all information.
Last Name First Name MI Former Name
Social Security Number† Date of Birth Gender: Male Female Marital Status: Single Married
Permanent/Home Address City State Zip County
( ) ( ) ( )
Home Phone Number Cell Phone Number Fax Number E-mail Address
Are you a U.S. citizen? Yes No If not, are you a permanent resident of the U.S.? Yes No
Country of citizenship (if not a U.S. citizen) __________________________
†The disclosure of your Social Security Number is optional. ChildCare Education Institute (CCEI) will use this information only for administrative
purposes, as more specifically set forth in our privacy policy. Non-disclosure will not affect your application in any way.
Do you hold a high school diploma? Yes No Name of High School Completed: ________________________________
City: ____________________ State: _____ Graduation Date: ________
If not, do you have a GED/High School Equivalency? Yes No GED/High School Equivalency Award Date: __________
If not, are you working towards a high school diploma or GED? Yes No Expected Graduation/Award Date: __________
Have you attended college before? Yes No Do you have a college degree? Yes No Date Awarded: _________
If not, do you plan to continue your education towards a college degree? Yes No
What is the highest level of education you have completed?
GED High School Some College Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree
Are you employed? Yes No If yes, do you work for a child care center or school? Yes No
Name of Employer
Employer Address City State Zip
( )
Business Phone Number Date of Employment
If you work at a child care center or school, please provide your Director's contact information:
( )
Director’s Name Director’s Email Address Director’s Phone Number
SECTION 1 – PERSONAL
SECTION 2 – RECORD
SECTION 3 – EMPLOYMENT
Form AP-09-001 (Rev. 6/27/11) Page 2 of 2
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.edu
©Copyright 2011, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes no guarantee of
employment, promotion, or retention.
I am registering for: Product Code:
Tuition Cost $
Application Fee $
Total Program Cost* $
*Textbook costs are additional and are the responsibility of the student.
Choose your method of payment:
Credit Card Authorization
VISA MasterCard American Express Discover
ACH Draft Authorization
Checking Savings
________________________________________________________________
Credit Card Number
____ /____ __________ ________________________________
Exp. Date CVV Code Billing Zip Code
________________________________________________________________
Card Holder’s Name (Please Print)
________________________________________________________________
Card Holder’s Billing Address (Please Print)
________________________________________________________________
Card Holder’s Signature
________________________________________________________________
Account Holder’s Name (Please Print)
________________________________________________________________
Account Holder’s Billing Address (Please Print)
________________________________ ______________________________
Bank Routing # Account #
________________________________________________________________
Name of Bank (Please Print)
________________________________________________________________
Account Holder’s Signature
Scholarship Provider: __________________________________________________________________________________________
I acknowledge that I am financially responsible for the unpaid balance of any fees not covered by my sponsoring agency or scholarship provider. I agree to the
option selected in the event that the funding I’ve applied for is not received. Full payment Withdraw application
I am aware of and meet the enrollment requirements of the certificate program I am applying for, including, but not limited to having a high school
diploma or GED, and understand that I must provide a copy of my diploma or GED within 30 days of enrollment.
I acknowledge that I have read and agree to the terms and conditions pertaining to this certificate program, including the refund policy. I am aware
of the program completion deadline and agree to abide by the rules and regulations of the CCEI student handbook as a condition of enrollment in
such program. I also acknowledge that I have five (5) days to cancel this enrollment and receive a full refund of Tuition Cost and Application Fees,
as long as I have not completed more than 1% of the coursework for such program. After five (5) days or the completion of more than 1% of
coursework, any refunds are subject to the CCEI withdrawal and refund policy. I agree to the above financial terms.
I certify that the information given in this application is true and correct to the best of my knowledge. I understand that misrepresentation, omission
of information or failure to complete the process may cause delay in the processing of the application or denial of admission to any program.
Print Name Signature Date
What made you decide to purchase today? (Please select one): Google Yahoo Bing (MSN)
Other Internet Search Engine Saw TV Ad Saw a Magazine Ad Saw an Internet Ad
Received something in the mail Received something via email Saw you on Facebook
Got a call from someone at CCEI Saw you at a trade show Referred by a Friend/Co-Worker Referred by Employer
Referred by NAEYC Connecticut Charts-A-Course Georgia Bright from the Start
Other: ______________________________________________________
Did your employer have any direct contact from CCEI that influenced your decision to purchase this training from CCEI?
Yes (please select one below) No Not that I know of
----------------------------------------------------------------------------------------------------
I, or my employer, received a call from a CCEI admissions representative
I, or my employer, received information in the mail from a CCEI admissions representative
I, or my employer, received an email from a CCEI admissions representative I, or my employer, received a renewal notice
I read information via email in the CCEI newsletter I received an email about something happening at CCEI that prompted me
I received an email with a promotion that prompted me I, or my employer, talked to someone at a trade show
Other: ______________________________________________________
Fax or mail the completed application to: ChildCare Education Institute
Attn: Admissions Department
3059 Peachtree Industrial Blvd.
Duluth, Georgia 30097
Fax: (877) 259-1105
SECTION 4 – PROGRAM/TUITION
SECTION 5 – CLOSING
Promo/Voucher/Group Code: _______________
(if applicable)
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Form TC-09-001 (Rev. 8/8/11) Page 1 of 5
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.com
©Copyright 2006, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes no
guarantee of employment, promotion, or retention.
CCEI
Online Certificate Program of Study
Terms and Conditions Acknowledgment
(English)
The party signatory hereto (“Student”) agrees, as a condition to, and in consideration of, the use of the services
provided by ChildCare Education Institute, LLC (“CCEI”) described herein to all of the terms and conditions set
forth in this Terms and Conditions Acknowledgment, including all exhibits attached hereto (this
“Acknowledgment”).
1.0 SERVICES. Subject to the terms and conditions of this Acknowledgment, and in consideration of the
payment of the fees set forth in Section 4 below, CCEI shall use reasonable efforts to provide to Student at a website
designated by CCEI (“Website”) a web-based instructional program (“Program”) comprised of coursework earning
CEUs, as listed on the “Tuition and Fee Schedule”). CCEI shall also make available to Student an Education Coach
fluent in the language of the program to support the Student in his/her completion of the Program (the Program and
such Education Coach services, collectively, the “Services”) for the term of this Acknowledgment as outlined in
Section 6.0. CCEI has the reasonable right, at its sole discretion, to change or modify the Services and the methods
and means by which they are provided, provided that the basic functionality and quality of the Services will not be
materially reduced.
2.0 COURSEWORK COMPLETION CERTIFICATE. CCEI will issue to Student a certificate confirming
completion of all coursework comprising the Program (the “Completion Certificate”) if Student (a) satisfactorily
completes such coursework comprising the Program in accordance with the terms and conditions of this
Acknowledgment and the Student Handbook, including terms relating to timelines for completion of such
coursework, (b) pays in full all amounts in respect of registration, tuition, books and fees for the Services
(collectively, the “Program Fees”), including without limitation, any such amounts that have been financed by CCEI
or its affiliates, and all other amounts owing hereunder and (c) submits documentation showing that they have a
minimum of a GED. CCEI does not grant the Child Development Associate Credential and does not guaranty that
any such Credential will be granted. Student acknowledges that he/she must contact the Council for Professional
Development for further details on requirements to receive the Child Development Associate Credential. Student
hereby acknowledges that he/she may obtain a current copy of the Student Handbook at
http://www.cceifame.com/pdf/student_handbook.pdf and he/she has read, reviewed and understands the provisions
in the Student Handbook and agrees to comply with all of the terms and conditions provided therein. Student hereby
further acknowledges that the Student Handbook may be amended at CCEI’s sole discretion from time to time and
Student will be responsible for complying with any such amended terms and conditions.
3.0 TERMS AND CONDITIONS OF SERVICES.
3.1 License to Access the Services. CCEI will grant to Student a nontransferable, non-exclusive, temporary
license for the term specified in this Acknowledgment, without the right to sublicense (the “License”), to access the
Website and use the software and course content part of the Program (the “Software”) solely for Student’s personal
training and professional development purposes in accordance with the terms and conditions of this
Acknowledgment and the Student Handbook. Student shall make no attempt to: (a) ) save, alter, modify, adapt,
translate, create derivative works of, merge with other software or content, improve, reverse engineer, disassemble
or decompile the Software, including without limitation the object and source code thereof or the content provided
on the Website; including without limitation, the content part of the Services (b) interfere in any manner with the
hosting of the Software, the hosting hardware or network, or the Program and content or Services associated
therewith; or (c) sublicense, distribute, sell, lease, rent, loan or otherwise transfer the Software, Website, Services, or
any of Student’s rights under this Acknowledgment or otherwise use or provide access to the Software, Website, or
Services for the benefit of any person other than Student, or operate a reseller service, time sharing, or other similar
service.
Form TC-09-001 (Rev. 8/8/11) Page 2 of 5
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.com
©Copyright 2006, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes no
guarantee of employment, promotion, or retention.
3.2 Security and Format of Services. Web access to and use of the Software and Services is through a
combination of an ID and a password, which will not be effective until activated by CCEI. Student shall keep its ID
and password confidential. Student will be responsible for all transactions entered through and under its Student ID
and any such transactions will be deemed to have been completed by Student. Use of the Software, Website, or
Services shall be deemed to be acceptance of all of the terms and conditions of this Acknowledgment. Student shall
be responsible for providing, at his/her sole cost, all telecommunications equipment, hardware, software, Internet
access and all other necessary equipment to connect, access and use the Website and the Services. Access to the
Services is subject to interruption at CCEI’s reasonable discretion for purposes of performing upgrades,
maintenance, backup and other necessary work. CCEI shall make reasonable efforts to notify Student of any
significant interruptions to the Services that may be reasonably anticipated and that are under the control of CCEI.
In addition, access to the Services may be interrupted from time to time due to unforeseen software, hardware,
equipment, network, power, Internet or other outages.
3.3 Student Data and User Information. Student will be solely responsible for providing CCEI with his/her
name, email address, and other relevant data for use by CCEI in performing the Services. Student acknowledges and
agrees that he/she is the only authorized user of the Website, Software, and Services on the subscriber account under
Student’s assigned ID and password, and he/she will not permit any access thereto by any third party. Any
Completion Certificates granted to, or earned by, invalid or unauthorized users will be rescinded and records of such
training will be deleted from said transcripts.
4.0 PRICING AND PAYMENT.
4.1 Payment of Program Fees. In consideration of the License and the Services provided to Student under this
Acknowledgment, Student shall pay CCEI the Program Fees, as outlined in the CCEI Tuition and Fee Schedule and
accommodating any active promotion where the valid promotion code is listed. Program Fees shall be payable on
the date of this Acknowledgment unless Student is eligible, and has applied, for funding from applicable scholarship
sources or third party financing from sources approved by CCEI and CCEI has received evidence of such eligibility
and completion of application. CCEI accepts VISA, MasterCard, American Express, and ACH Debit Processing as
forms of payment. Unless Student elects to obtain a refund pursuant to the conditions specified in Exhibit A
attached hereto, all Program Fees not paid on the date of this Acknowledgment shall be due and payable on the
earlier of the date of receipt of any scholarship or financing funding or on the date of receipt by CCEI of any denial
of payment of any amount of funding of the Program Fees from any scholarship or financing source. Any amounts
remitted by, or received by Student from, any such scholarship or financing source for Student’s account in respect
of the Program shall be promptly remitted to CCEI and applied to the Program Fees. Student acknowledges that any
such scholarship or financing may have its own eligibility criteria and terms and conditions and he/she is solely
responsible for obtaining or maintaining such eligibility for any such funding, including without limitation from any
sources approved by CCEI. CCEI will have no obligation in connection with Student obtaining or maintaining any
such funding. Student acknowledges that he/she is solely responsible for payment in full of the entire Program Fees
and any failure to receive any partial or full funding from any other scholarship or financing source will not affect
Student’s obligation to pay in full all Program Fees. CCEI reserves the right to change pricing terms for the
Services at any time, unless otherwise specifically agreed in writing by CCEI.
4.2 Non-payment of Program Fees. CCEI reserves the right to suspend, disconnect, or otherwise terminate
immediately, Student’s access to the Software, Website, or Services in the event of non-payment of any Program
Fees at the time due in accordance with this Acknowledgment and any Order Form. On any and all Program Fees
past due, Student agrees to pay interest at the lesser of 1.5% per month or the then-highest interest rate allowable
under applicable law. Student is responsible for all costs and expenses of CCEI in enforcing this Acknowledgment,
including without limitation, reasonable legal and collection fees. Student may reinstate enrollment in the Program
after any such termination resulting solely from non-payment upon payment, within 15 days of the date of any such
termination for non-payment, of a reactivation fee of $25.00 and payment in full of all Program Fees and other
amounts then owing hereunder; provided, however, Student must still meet all eligibility criteria, including without
limitation, time deadlines for coursework completion, otherwise applicable to receive a Completion Certificate.
Form TC-09-001 (Rev. 8/8/11) Page 3 of 5
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.com
©Copyright 2006, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes no
guarantee of employment, promotion, or retention.
4.3 Drop/Refund Policy. Notwithstanding anything to the contrary herein, Student shall not be entitled to any
partial or full refund or abatement of any Program Fees paid or payable prior to or after termination or completion of
the Program or Services for any reason except as specifically provided pursuant to the Drop/Refund policy described
in Exhibit A attached hereto.
5.0 TITLE TO SERVICES, PROPRIETARY INFORMATION AND TRADEMARKS.
5.1 Title to Services. CCEI retains (i) all right, title and interest in and to the Software, Website, and Services and
all related documentation and materials, and (ii) all copyrights, patent rights, trade secret rights and other proprietary
rights in the Software, Website and Services.
5.2 Website, Services and the associated documentation. Student agrees that CCEI shall have any and all right,
title and interest in and to any and all modifications, design changes, upgrades, or improvements of the Software,
Website, and Services, whether or not suggested by Student, without the payment of any additional consideration
therefore to Student.
5.3 Proprietary Information. All information and the terms and conditions of this Acknowledgment shall be
considered “Proprietary Information” of CCEI. Student further acknowledges that CCEI’s Proprietary Information is
deemed to include valuable trade secrets and confidential business information proprietary to CCEI and/or third
parties providing services to CCEI. Accordingly, Student shall hold the Proprietary Information disclosed by CCEI
confidential and use such Proprietary Information only in connection with Student’s receipt and use of the Services.
5.4 Trademarks. The trademarks and trade names, whether registered or unregistered, associated with the
Software, Website, and Services are the exclusive property of CCEI. This Acknowledgment gives Student no rights
therein. Student shall not use CCEI's trademarks and trade names in any manner, including without limitation, on
any advertising or promotional materials, except with the prior written consent of CCEI.
6.0 TERM AND TERMINATION. This Acknowledgment shall terminate upon the earlier to occur of any of the
following: (a) completion of the Program, (b) termination by CCEI or Student upon written notice to the other
person if the other person materially breaches this Acknowledgment and does not cure such breach within 15 days
after written notice of such breach (c) termination by Student in accordance with Drop/Refund Policy described in
Exhibit A attached hereto and (d) the program end date or the last date of any extension granted pursuant to the
Student Handbook. Upon the termination of this Acknowledgment for any reason, the License granted herein shall
immediately terminate and Student’s access to the Software, Website, and Services shall be immediately terminated.
The rights and duties of CCEI and Student under Sections 4, 5, 7, 8, 9, 10 and 11 shall survive the termination or
expiration of this Acknowledgment.
7.0 LIMITED WARRANTY AND DISCLAIMER.
7.1 Limited Warranty. CCEI’s sole obligation, and Student’s exclusive remedy, for any failure or interruption in
the Services, or breach by CCEI of any warranties or other obligations under this Acknowledgment, shall be to
terminate this Acknowledgment as provided in Section 6, in the event of a material breach by CCEI, or require
CCEI to use reasonable efforts to restore access to the Services as soon as reasonably possible and/or to cure such
breach.
7.2 Disclaimer. Except as expressly set forth in this Section 7.2, the Services and all other data and materials
provided in connection with this Acknowledgment by CCEI and its suppliers are provided “AS IS” and “AS
AVAILABLE,” without representations or warranties of any kind. TO THE FULLEST EXTENT PERMISSABLE
UNDER APPLICABLE LAW, CCEI MAKES NO OTHER WARRANTIES OR CONDITIONS, EXPRESS OR
IMPLIED, BY OPERATION OF LAW OR OTHERWISE, INCLUDING, WITHOUT LIMITATION, ANY
WARRANTY OF NONINFRINGEMENT OR ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR
Form TC-09-001 (Rev. 8/8/11) Page 4 of 5
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.com
©Copyright 2006, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes no
guarantee of employment, promotion, or retention.
FITNESS FOR A PARTICULAR PURPOSE OR ANY IMPLIED WARRANTIES ARISING OUT OF COURSE
OF PERFORMANCE, COURSE OF DEALING OR USAGE OF TRADE. CCEI DOES NOT WARRANT THAT
THE SERVICES WILL BE PROVIDED ERROR-FREE OR UNINTERRUPTED. In addition to any disclaimers set
forth elsewhere in this Acknowledgment, Student agrees and acknowledges that CCEI shall in no event be held
responsible for any problems with the Services attributable to the public Internet infrastructure or Student’s ability to
connect to the Internet. Additionally, Student acknowledges and agrees that CCEI shall not be responsible for any
defect, failure or non-conformity resulting from improper use, neglect, accident, unreasonable use, or modification
by Student or any third party.
8.0 LIMITATION ON DAMAGES. In the event CCEI is found to be liable for any breach of its obligations
hereunder, its liability shall be limited to the amount of Program Fees paid by Student to it hereunder. CCEI shall
not be liable for any claims, losses, or damages of Student or any other individual or entity or for lost profits or any
special, indirect, incidental, consequential, or exemplary damages or the costs of procurement of substitute products
or services arising under this Acknowledgment, howsoever arising, even if CCEI has been advised of the possibility
of such damages in advance.
9.0 ASSIGNMENT. Student may not assign or transfer all or any portion of its rights or obligations under this
Acknowledgment without the prior written consent of CCEI. CCEI may assign its rights and delegate its obligations
under this Acknowledgment to any third party.
10.0 GENERAL. This Acknowledgment, any related Fee Schedule or Order Form, and the Student Handbook
constitutes the entire understanding and agreement of CCEI and Student, and supersede any and all oral or written
agreements or understandings between Student and CCEI, as to the subject matter hereof. In the event of any
conflict between the Order Form, Student Handbook and this Acknowledgment, this Acknowledgement shall
govern. The failure by CCEI or Student to enforce any right or claim against the other person shall not be construed
as a waiver by such person of any such right or claim and any waiver by such person of any breach hereof shall not
be construed as a waiver of any subsequent breach. This Acknowledgment shall be governed by and construed in
accordance with the laws of State of Georgia applicable to agreements made and to be performed within the State of
Georgia, without regard to its conflict of laws provisions. If any provision of this Acknowledgment shall be held by
a court of competent jurisdiction to be illegal, invalid or unenforceable, the remaining provisions shall remain in full
force and effect. No modification or waiver of any provision of this Acknowledgment shall be effective unless made
in writing and signed by CCEI and Student.
11.0 PRIVACY OF INFORMATION. Personal information of Student provided to CCEI is used solely for the
purpose of administering Services as outlined under this Acknowledgment and in connection with reporting to state
and federal agencies or workforce registries. Pursuant to the Privacy Act, 5 U.S.C. Section 522A, Student’s
disclosure of his/her social security number is voluntary. Student’s social security number will be used for
governmental statistical purposes. CCEI will not share or sell to third parties not affiliated with CCEI any personal
information of Student for the purpose of marketing, list accumulation or solicitation. CCEI may, from time-to-time,
communicate with Student via email, fax, phone, or mail using the personal information provided for
communication in connection with the Services and/or marketing of additional products offered by CCEI or its
affiliates.
Form TC-09-001 (Rev. 8/8/11) Page 5 of 5
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.com
©Copyright 2006, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes no
guarantee of employment, promotion, or retention.
EXHIBIT A
CERTIFICATE PROGRAM DROP/REFUND POLICY
So long as Student is not in breach of the Acknowledgment, Student may at any time, prior to their program
end date, request withdrawal from their certificate course of study. The “Effective Date of Termination”
will be the date that the student notifies CCEI, and receives a confirmation of notification, that they want to
withdraw from the program. CCEI requires students to complete an Official Withdrawal Notification Form
(available online), for withdrawal processing to occur, but the “Effective Date of Termination” will be the
date of first confirmed notification. Receipt by CCEI of such Official Withdrawal Notification Form may
be by means of facsimile, e-mail or postal mail. Student acknowledges that he/she is responsible for
obtaining confirmation of withdrawal notification and receipt of form.
Students who withdraw within 5 days (considered the ‘grace period’) of enrollment and who have
completed less than 1% of the Program will receive a full refund of Tuition Cost and Application Fees.
Students who withdraw after the grace period or who have completed at least 1% of their Program, will be
eligible for refunds based on the following chart. The chart shows the percent of Tuition Cost to which
Student will be entitled based on number of days of enrollment in the Program (calculated from the
Effective Date of Termination) or the percentage of completion of the coursework completed prior to the
Effective Date of Termination. Such refund amount will be calculated based on the higher of percentage
days completed or percentage coursework completed. (For example, if Student has been enrolled in the
Program for 4% of the allowable days prior to termination and has completed 20% of the Program, the 20%
figure will be used to calculate the refund. If Student has been enrolled in the Program for 30% of the
allowable days and has completed 15% of the Program, the 30% figure will be used.)
GREATER OF
% of % of
Enrollment Program Tuition Cost
Period Completion Refunded or Abated
Less than 5% of allowable days Less than 5% 95%
5-10% of allowable days 5-10% 90%
10-25% of allowable days 10-25% 75%
26-50% of allowable days 26-50% 50%
Over 50% of allowable days Over 50% 0%
CCEI will refund any Tuition Cost to which Student is entitled and for which it has received payment from
student within 30 days from the receipt of the Official Withdrawal Notification Form.
If Student is unable to complete a Program because of a cancellation or material change in the Program by
CCEI, CCEI will use reasonable efforts to make accommodation to allow Student to complete the Program.
If CCEI is unable to provide a means for completion of the Program to Student, then within 30 days of the
date of determination by CCEI that it will be unable to allow Student to complete the Program, CCEI will
refund all Program Costs it has received from Student.
Form CCEI-SF-AU01 (rev. 1/1/09) Page 1
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.com
©Copyright 2006, 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 the persons and entities listed below as "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.
AUTHORIZED RECIPIENTS:
Name: ____________________________________
Name: ____________________________________
Name: ____________________________________
_____________________________________________ ___________________
Student Signature Date
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Certificate Program Enrollment Application (ChildCare Education Institute)

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