ICC NOW Student/Parent Consent Form

ICC NOW Student/Parent Consent Form

Student Information

Student Information*

First Name

Last Name

Phone Number*

Can text reminders be sent to this number?*

Email*

High School *

REMINDER:

Each student must complete a FERPA form before any information can be released to anyone besides the student.

Parent/Guardian Information

*

First Name

Middle Name

Last Name

Relationship to student *

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Parent/Guardian Email

Phone Number

Can text reminders be sent to this number?

Important Information

• Each student will pay an ICC NOW tuition rate of $65 per credit hour unless it is an Excel in CTE approved course.

• Consumable fees may apply depending on the course. This would include fees like: codes, workbooks, equipment, etc.

• Students will not be permitted to enroll in any further course(s) until their term balance is paid in full or a current payment plan is set up.

Course Information

Semester the courses will be taken:*

1. Course Name and Location*

2. Course Name and Location

3. Course Name and Location

4. Course Name and Location

5. Course Name and Location

ICC does not discriminate on the basis of race, religion, color, national origin, sex, age, tenure, disability or any other factors that cannot be lawfully considered in its programs and activities as required by all applicable laws and regulations.

Important information About Your ICC Bill

I assume full responsibility for the expenses incurred for the cost of my education (tuition, fees, books, housing, meals, etc.) with Independence Community College (ICC) and I understand it is my obligation to pay for the costs that are set forth in this agreement made between me and ICC. To that end, I agree 1) To allow ICC to automatically collect payments from me using an authorized debit or credit card, employing the terms defined above, through its credit card servicer; 2) To authorize ICC to collect from me an additional $15 for the cost of my education and/or housing for administrative fees.

After having read this agreement in its entirety, I further understand that: 1) If my payment information changes (name, address, account information, etc.), I will notify the ICC Business Office immediately; I also understand that any change of address returned by the US Postal Service will result in additional charges to my account; 2) The amount of money I owe ICC may increase if I add coursework in this or in subsequent semesters, if I charge items unaccounted for in this agreement to my student account, if I incur other charges or fines at ICC, or if a grant or scholarship is denied or revoked; 3) My ICC account balance may not decrease if I fail to properly drop one or more classes, of if I fail to properly check out of the dormitory, or if I fail to properly return my rental books on time; 4) My ICC account balance may increase if I drop classes, either properly or improperly, that put me below the minimum credit hour threshold to receive financial aid; and 5) If I fail to make payment or if any payment I make to ICC is denied, rejected or terminated for any reason, I understand that: a) the amount of the denied, rejected or terminated payment becomes payable in full immediately using cash, a cashier's check or different debit or credit card in the ICC Business Office, b) if after 10 business days I still have not made my payment in full to ICC, my account balance may be turned over to collections and collection agency fees and attorney's fees may be added to what I owe, c) if my payment is denied, rejected or terminated and I fail to meet my obligation above, I may be dropped/withdrawn from coursework or classes, d) my grades, transcripts, or other records with ICC may not be released until I completely pay any balance I owe, and e) enrollment in any subsequent classes or coursework with ICC may be denied until such time my account with ICC is paid in full, and thereafter enrollment may be on a "cash in advance only" basis. By my signature below, I affirm that I will fulfill the terms set forth in the agreement and that I have asked questions and understand my obligations to ICC under this agreement.

Consent For Student and Parent/Guardian to Complete

Student Acknowledgement

1. I understand this is college level course work. College classes require rigorous academic work.

2. I understand the grades received will become a part of my permanent college transcript.

3. I understand that Independence Community College will release college grade(s) to the attending high school.

4. I understand in order to receive credit I must return this consent form and submit payment to ICC.

5. I understand it is my responsibility to drop or withdrawal from class by deadline or all requirements of class must be met.

6. I understand that if I transfer to a different school during the school year it is my responsibility to complete the necessary drop/withdraw paperwork and I will still be responsible
to pay for the course(s) if it is past the last day to drop. (If the new school offers the course/s that you are enrolled in, your enrollment can be transferred to that school but you must notify ICC about the transfer.)

7. I understand I may participate in campus visits where photographs, video, or audio recordings may be taken. These may be used in promotional materials for Independence Community College.

By clicking Yes you agree to abide by the Terms of Service outlined above.

Student Signature

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Parent/Guardian Acknowledgement

1. I have read the information above and understand the conditions of my student's enrollment.

2. I understand these are college courses and the discussions may include adult topics.

3. I understand tuition and fees must be paid to Independence Community College.

4. I understand my child may participate in campus visits where photographs, video, or audio recordings may be taken. These may be used in promotional mate-rials for Independence Community College

By clicking Yes you agree to abide by the Terms of Service outlined above.

Parent /Guardian Signature

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