Consent Forms
Please read the following details carefully and provide your consent below.
1. Participant Information Disclosure
I understand that the information provided in this application will be used only for eligibility determination and federal reporting requirements for the Veteran Student Support Services (VSSS) Program at Salt Lake Community College (SLCC).
All information will remain confidential and will not be shared outside the program except as required by law or federal regulations.
2. WRITTEN NOTICE OF BENEFICIARY PROTECTIONS
In accordance with the Education Department General Administrative Regulations (EDGAR), 34 C.F.R. § 75.712,
all grantees providing social services under a Department program supported by direct Federal financial
assistance (e.g., programs that provide or support employment, independent living, education, or related
services to individuals or groups of individuals) must give written notice to a beneficiary or prospective
beneficiary of certain protections.
3. Photographic Release
I authorize SLCC’s TRIO Veteran Student Support Services (VSSS) Program to use my photograph, video, or likeness for educational, informational, or promotional purposes.
I understand that participation is voluntary and that I may revoke this consent at any time by submitting written notice to the program.
I authorize TRIO SSS to gather information concerning my academic progress and financial aid status. I understand that this information is used to assist in the determination of my eligibility for TRIO SSS and it will strictly confidential. I grant permission for TRIO SSS to gather information for follow-up whenever appropriate, including transfer and progress at 4-year institutions. I am aware that TRIO SSS reports to the U.S. Department of Education in accordance with the grant funding regulations. I certify that the information provided on this application is true and complete to the best of my knowledge. I agree to provide documentation upon request to verify the information reported. I am aware that the personal information provided to TRIO SSS is protected under the Family Education Rights and Privacy Act of 1974.
*
Additional instructions for the previous question. Information consent
TRIO SSS is required to provide you the following information:
(1) TRIO SSS may not discriminate against you on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to attend or participate in a religious practice.
(2) TRIO SSS may not require you to attend or participate in any explicitly religious activities (including activities that involve overt religious content such as worship, religious instruction, or proselytization) that may be offered by our organization, and any participation by you in such activities must be purely voluntary.
(3) TRIO SSS must separate in time or location any privately funded explicitly religious activities (including activities that involve overt religious content such as worship, religious instruction, or proselytization) from activities supported with direct Federal financial assistance.
(4) You may report violations of this protection, including any denials of services or benefits by an organization, by filing a written complaint with the U.S. Department of Education at
BeneficiaryNoticeComplaints@ed.gov.
*
Additional instructions for the previous question. Photographic release
I hereby give TRIO SSS and Salt Lake Community College the unqualified right and permission to reproduce, copyright, publish, circulate or otherwise use my name and/or photographic likeness of me still, single, multiple or moving in which I may be included whole or in part, or composition. I understand that my photo may be used in publications under the direction of TRIO SSS or Salt Lake Community College. I waive any right to inspect and approve the finished product or copy that may be used or the use to which it may be applied. The authorization and release cover the use of said materials in any published or broadcast form.
Additional instructions for the previous question. Photographic release
