Fillable SPONSORED STUDENT BILLING AUTHORIZATION! (Kellogg Community College)

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SPONSORED STUDENT BILLING AUTHORIZATION! (Kellogg Community College)

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REGIONAL MANUFACTURING TECHNOLOGY CENTER
SPONSORED STUDENT BILLING AUTHORIZATION!
STUDENT CONFIDENTIALITY, GRADES,
AND SCHEDULE ADJUSTMENTS (DROPS)
LAST NAME, FIRST NAME, MIDDLE INITIAL!
DATE OF BIRTH!
CURRENT PHONE!
KCC ID NUMBER (K-ID)!
I understand that as a sponsored student my company/agency may require access to confidential information as a condition of
sponsorship. I understand that by completing this form I am agreeing to release the following information:
• Attendance records, which may include sign-in sheets or time clock reports.
• Academic integrity, which may include misuse of the time clock or cheating.
• Academic hardship, which may include excessive difficulties with certain areas of study such as math and reading.!
Further, I understand that as a sponsored student my company/agency may require access to my grades. I understand that by
completing this form, I am agreeing to release a progress report which will include module start dates, completion dates, and grades
(pass or incomplete). I understand that this release of information will remain in effect for this semester’s information and data.
I understand that for billing purposes, excluding forklift and assessment modules, incomplete modules will be dropped from my record
at the end of each semester and will need to be re-authorized and re-registered for in the next semester.
By signing this form, I agree and accept the terms as stated above.
STUDENT SIGNATURE
DATE!
PROGRAM INFORMATION
PROGRAM NAME!
COMPANY PROGRAM ID#!
STUDENT MUST PUNCH
TIME CLOCK AT RMTC
NO
DOL (DEPT. OF LABOR)
REGISTERED APPRENTICE? NO
MODULE SUBJECT CODE
AND NUMBER:
MODULE SUBJECT CODE
AND NUMBER:
MODULE SUBJECT CODE
AND NUMBER:
MODULE SUBJECT CODE
AND NUMBER:
MODULE SUBJECT CODE AND
NUMBER:
1)!
3)!
5)!
7)!
9)!
2)
4)!
6)!
8)!
10)!
Students will register for modules per this authorization.!
BILLING AND SPONSOR APPROVAL
1. New students must complete a Program Orientation module for each program of study (INEL, INMT, etc.).!
2. Billing authorizations are due when the student is ready to register for a set of modules. Please allow five business days for the
authorization to be processed.
3. Each semester, sponsored students must complete the KCC registration process online or in person. Students must register for
all modules listed on this authorization within the semester identified. Students will be invoiced directly for any registration activity
outside the scope of this authorization.
4. The company/agency noted below will be invoiced for completed modules at the end of the semester. Excluding forklift and
assessment modules which must be invoiced, companies will not be billed for incomplete modules. For billing purposes, incomplete
modules will be dropped from the student’s record at the end of each semester and will need to be re-authorized and re-registered fo
r
in the next se
meste
r.
5. All modules at the RMTC are competency-based. Students do not complete modules or earn a “Pass” grade until they achieve the
minimum competency level established for the module (80%, 90%,
or 100%). Competency levels are clearly stated in each syllabus.
6. By returning this billing authorization form, the sponsor is authorizing KCC to invoice the company/agency for training costs
incurred by the student for the modules listed above.
COMPANY/AGENCY NAME!
STREET!
PHONE!
CITY!
STATE!
ZIP!
FAX!
AUTHORIZED BY (SIGNATURE)!
EMAIL!
PRINTED NAME!
TITLE!
DATE
Return this form to: Kellogg Community College / E-Mail rmtc@kellogg.edu / Fax: (269) 962-7370 / Phone: (269) 965-4137
STAFF USE ONLY!
XO6
STSP
NEW STUDENT
TIME CLOCK
Please see reverse for additional Authorization for the Release of Student Information document that student
must sign for FERPA privacy laws, if releasing any portion of his/her course history to the company.
YES
YES
REVISED 5/1/19
AUTHORIZATION*FOR*THE*RELEASE*OF*STUDENT*INFORMATION*
TO!WHOM!IT!MAY!CONCERN:!
I!hereby !a u th o riz e !K ello g g !C o mmun ity !C o lle ge !t o !re lea s e!a n d / o r!o r ally !d isc u s s!the!educ a tio n !r ec o rd s !d e sc rib e d !b e lo w !
about!me!to:!Designated*representatives*at*my*company*–*Human*Resources,*direct*supervisors,*and*company*
leader sh ip .!
The!specific!records!covered!by!this!release!are:!My*student*course*history*sponsored*by*the*company*listed*on*
reverse/first*side*of*this*document*–*the*Sponsored*Student*Billing*Authorization*form.*
The!persons!to!whom!the!information!may!be!released,!and!their!representatives,!may !use!th is!inform a tion !for!the !
following!pu rpo se s:!Purposes*as*outlined*in*individual*company*policies.!
I!under st an d !t h a t!th e !s tu d e n t!r ec o rd s !in fo r m a tio n!listed!ab o v e !in clu d e s !in fo rmation !w h ic h !is!c la ss ifie d !as !p riv a te !u n d e r!
the!federal!Fam ily!E du ca tion !Righ ts!an d!P rivacy !Ac t,!20!U.S .C.!12 32(g ).! !
I!under st an d !t h a t!b y !sig n in g !th is !Re le a se !o f!In fo r mation!fo r m !I!a m!auth o rizing!Kellog g !C o mmun ity !C o lle ge !to !r e lea se !t o !
the!persons!n am e d!ab ov e,!and !the ir!repre sen tative s,!inform atio n!w h ich!would!otherwise!be!private!and!not!accessible!
to!them.!!
I!under st an d !t h a t!without !my!informed!co n se n t,!K e llo gg !C o mmun it y!C o lle g e !co u ld !n o t !re le as e !th e !in fo rmation !d es c rib e d !
above!because!it!is!classified!as!private.!
I!under st an d !f u rth e r !th a t:!!(1 )!I!have!the!right!not!to!consent!to!the!release!of!my!education!records;!(2)!I!have!the!right!
to!receive!a!copy !of!suc h!rec ord s!up on !requ es t;!and !(3)!that!th is!con sen t!sha ll!rema in!in!effe ct!un til!revoke d!b y!m e,!in!
writing,!but!that!any!such!revocation!shall!not!affect!disclosures!made!by!Kellogg!Community!College!prior!to!the!receipt!
of!any!such!written!revocation.!!
This!information!is!released!subject!to!the!confidentiality!provisions!of!FERPA,!which!prohibits!any!further!disclosure!of!
this!information !with out!the!specific!written!consent!of!the!person!to!whom!it!pertains.!
I!am!givin g !th is !co nsent!fre ely !a n d !vo luntarily,!and!I!und e rs ta n d !th e !c o n se q u e n ce s !o f!my!giving !th is !co n s e n t.!
Student!Signature!___________________________________!!Date_________________!
Printed!Student!Name:!!________________________________K-ID___ _ __ _ _ _ _ _ _ _ __ _ _!
Date!of!Birth:_____________________________!Last!4-digits!of!SSN:________________!
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SPONSORED STUDENT BILLING AUTHORIZATION (Kellogg Community College)

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Completed 26 July 2020

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