Confidentiality Statement

Kennesaw State University
Bagwell College of Education

Center for Education Placements and Partnerships
ONLINE CONFIDENTIALITY STATEMENT

Please fill out this confidentiality form as a reminder not to disclose any CONFIDENTIAL student data while you are completing your online practicum experience.

If you see this don't fill out this input box.

Today's Date:

Full Name:

KSU #:

Address 1:

Address 2:

City / Sate / Zip Code:

Email Address:

Phone Number:

Recognition Statement #1

I have read, understand, and agree to Recognition Statement #1, which states the following:

I understand that I do NOT have a GaPSC Professional Certificate, and therefore, I am not eligible for certification in Instructional Technology offered by the GaPSC.

Recognition Statement #2:

I have read, understand, and agree to Recognition Statement #2, which states the following:

I understand that I am not eligible for an upgrade to my teaching certificate from the GaPSC, since I do not have a GaPSC Professional certificate.

Recognition Statement #3:

I have read, understand, and agree to Recognition Statement #3, which states the following:

I understand that the degree in Instructional Technology may not lead to a pay increase from my school or district since I do not have a GaPSC Professional certificate.

Recognition Statement #4:

I have read, understand, and agree to Recognition Statement #4, which states the following:

I understand that if I were to attain a GaPSC Professional certificate in the future, that I may still not be eligible for certification in Instructional Technology since I did not have a GaPSC Professional certificate at the time I enrolled in the Instructional Technology degree program at KSU.

Electronic Signature:

Entering my first name, middle initial, and last name in the box above indicates my electronic signature on this form.

Confidentiality Statement

Kennesaw State University Bagwell College of Education

Kennesaw State University
Bagwell College of Education