Confidentiality Statement

Center for Education Placements and Partnerships

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 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.