Middle College Parent Authorization Form

Please read this page in its entirety. Your electronic signature at the bottom of this page is required for your student to be admitted to the Middle College program at APSU. Please contact Heather Mendoza at (931) 221-1350 or Heather.Mendoza@cmcss.net with any questions.

Your Student's First Name*List your student's information, not your own

Your Student's Last Name*List your student's information, not your own

Your Student's Date of Birth*

Hepatitis B (HBV)*Please select the appropriate statement as it refers to your student.

Date of Completion of the HBV SeriesIf your student has not completed the vaccination series, please type "NA".

Meningococcal Meningitis*Please select the appropriate statement as it refers to your student.

Date of Completion of the Meningococcal Meningitis Vaccine*If your student has not received the vaccine, please type "NA".

ELECTRONIC SIGNATURE ACKNOWLEDGMENT AND CERTIFICATION OF UNDERSTANDING

This certifies that I have read the concurrent enrollment policies and I hereby give permission for my son/daughter to enter the program as outlined.

ELECTRONIC SIGNATURE. This Acknowledgment and Certification of Understanding ("Acknowledgment") is to let you know that by submitting an electronic signature, you are providing an electronic mark, that is held to the same standard as a legally binding equivalent of a handwritten signature provided by you. For purposes of the acknowledgment, a digital mark is considered a typed legal First and Last name (legal name may include middle name, initial or suffix) followed by the typed date. Any document requiring an electronic signature may contain a signature acknowledgment statement provided in the same area requiring the electronic signature.

AGREEMENT: By signing this Acknowledgment, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

CERTIFICATION OF UNDERSTANDING: I also understand, acknowledge, agree and certify that:

• I accept my responsibilities in the use of electronic signatures as described on this form.

Parent/Guardian E-Signature*Please include your first and last name.

Phone NumberPlease provide your phone number, not your student's.

Form submission can take up to 5 minutes to be received. Please be patient after submitting this form.

If you receive a message to contact system administrator, please send an email to admissions@apsu.edu to see if admissions has received the parent form before submitting another one.

Thank you!