Lavelle - Brother Kearney Scholarship Program Waiver and Release Form

Student Name(Required)

First Last

1. I agree to the release of the following information on an as-requested basis without further consent and until further written notice. This authorization shall be considered as a waiver of any and all my rights and/or privileges including the right to access confidential references given for any of the purposes listed below. Selecting "I Do Not Agree" to any items on this form will indicate my complete withdrawal from the Lavelle - Brother Kearney Scholarship Program.(Required)

I Agree
I Do Not Agree

2. Education data from the student’s high school, college/university, including personally identifiable information such as grades, transcripts, enrollment status and any information pertaining to the applicant’s education at other institutions previously attended.(Required)

I Agree
I Do Not Agree

3. Financial aid data from the college/university in determination of the Scholarship amount.(Required)

I Agree
I Do Not Agree

4. Evaluation and assessment information from professionals who have interacted with the applicant including (but not limited to) parents, Vocational Rehabilitation Counselors, teachers, school/guidance counselors, professors, college advisors, Disability Services representatives, technology instructors, and orientation and mobility instructors.(Required)

I Agree
I Do Not Agree

5. Employment data from the college/university, external service provider, and/or state Vocational Rehabilitation office, including details of internships held during undergraduate/graduate studies and jobs obtained up to 5 years after program completion.(Required)

I Agree
I Do Not Agree

Primary Phone(Required)

Select College or University(Required)

School ID

Is student under 18 years of age?(Required)

Yes
No

If under 18, Legal Guardian's signature format::(Required)

Using mouse or stylus
Keyboard entry

Signature of Legal guardian (if student is under 18) - You are authorizing the use of this electronic signature by signing in the field below.(Required)

e-Sign - Legal Guardian (if under18) -You are authorizing the use of this electronic signature by typing in the text field below.(Required)

Select student's signature format:(Required)

I will use a mouse or stylus.
I will sign using the keyboard.

Student Signature - You are authorizing the use of this electronic signature by signing in the field below. Use your mouse or stylus.(Required)

Student E-Sign - You are authorizing the use of this electronic signature by typing in the text field below.(Required)

Date (mm dd yyyy)(Required)

Enter your school email address. A copy of this form will be sent to you.(Required)

Enter Email Confirm Email

Student Phone

Name

This field is for validation purposes and should be left unchanged.